Avir at Schertz

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation that LVN B and LVN C recorded in the March 2026 TAR (Treatment Administration Record) that the resident received wound care on 3/9/26, 3/12/26, 3/15/26, and 3/16/26. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to nursing and medical staff involved in wound care given to residents.

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 from 1 of 1 kitchen observed for safe food handling practices. The DM failed to ensure weekend kitchen staff deep cleaned the convection oven. Cook P failed to cover the four cooking sheets of chocolate chip cookies and to allow the plate covers (domes) to air dry before stacking them. The DM failed to ensure lunch items (pork chop with gravy, mixed vegetables and whipped sweet potatoes (regular diet) maintained safe range temperature on 2/26/26. The facility failed to ensure the handwashing sink in the kitchen was functional. These deficient practice could place residents at risk of food borne illnesses and result in a decline in the resident's health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff disposed of garbage and refuse properly in 1 of 1 dumpster reviewed for disposal of trash. The facility failed to ensure the grounds around the dumpster were clean and free from food items. This deficient practice could place residents at risk for rodent and insect activity in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 3 of 8 residents (Resident #3, Resident #4 and Resident #23) whose records were reviewed for PASARR services. The facility failed to include Resident #3, Resident #4, and Resident #23's mental health status was coded on the PASARR screening Level I.These deficient practices could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident and identify the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 24 Residents (Resident #3, #20, #23, #18, and #19) whose records were reviewed for resident needs. Nursing staff failed to identify in Resident #3's care plan her mental health status, care and services she required. Nursing staff failed to identify in Resident #20's care plan his behavior of removing his colostomy bag and throwing it on the floor. The facility failed to ensure Resident #23's care plan included his being a smoker. The facility failed to ensure Resident #18's care plan reflected the cares for the resident's wound and tube feeding. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Residents #43 and Resident #48) and in 1 of 4 rooms (room [ROOM NUMBER]) reviewed for respiratory care.1. Resident #43's CPAP (continuous positive airway pressure) mask was not covered in a plastic bag when it was not used on 02/24/2026.2. The facility failed to ensure Resident #48 did not have a physician's order for oxygen that was observed being used on 02/24/2026 and 02/27/2026.3. The facility failed to store 2 portable oxygen cylinders in the designated oxygen storage room. This failure could place residents at risk of illness, respiratory complications and accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (B-hall nursing cart and A-hall nursing cart) out of 3 medication carts and 2 (Resident #61 and #30) out of 3 residents reviewed for pharmacy services. 1. There were three bottles of sterile water that expired 02/09/2026 and one spray bottle of safe simple-odor eliminate clear lubricant for ostomy pouch that expired 09/02/2025 found inside the B-hall nursing cart on 02/25/2026. 2. There was one bottle of Geri care Iron supplement liquid ferrous sulfate 220 mg/5ml that expired on 07/2025 and one bottle of calcium carbonate 500 mg that expired on 01/2026 found inside the A-hall nursing cart on 02/25/2026. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 4 (Resident #71, #7, #5, and #56) of 24 residents reviewed for infection control practices. 1. When the facility ADON was providing wound care to Resident #71 on EBP (Enhanced Barrier Precaution), the ADON did not wear a gown, and the facility did not attach the sign of EBP on the door of the resident. 2. When CNA-L was providing urinary indwelling catheter care to Resident #7 on EBP (Enhanced Barrier Precaution), the CNA-L did not wear a gown. 3. When CNA-O was providing incontinent care to Resident #5 on 02/26/2026, the CNA-O touched new and clean brief with old and dirty gloves. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the facility implemented and maintained an effective training program for all existing staff for 4 of 8 staff (MA G, MA I, CNA J and CNA K) whose records were reviewed for training. The facility failed to ensure MA G, MA I, CNA J and CNA K completed the required yearly competency skill set training. This deficient practice could place residents at risk of being cared by unqualified nursing staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #3) out of 24 residents reviewed for dignity. When LVN-M administered a medication to Resident #3 via the resident's gastrostomy tube on 02/26/2026, the nurse did not provide privacy, and as a result, the resident's roommate saw everything regarding how the nurse gave a medication via gastrostomy tube. These failures could place the residents at risk of not having their right to privacy and to a dignified existence maintained.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance 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 prefers for 1 (Resident #5) out of 24 residents reviewed for resident rights. The facility failed to obtain informed consent for the use of Risperdal (an antipsychotic medication) for Resident #5. These failures could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 8 residents (Resident #15 and Resident #65) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #15 and Resident #65. This deficient practice could place residents at risk of not being able to call for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 (Resident #5) of 24 residents reviewed for chemical restraint, in that: The facility failed to ensure Resident #5 was prescribed Risperidone for restlessness and agitation, no longer than 14 days PRN (as needed). This failure could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 10 Residents (Resident #3 and Resident 42 whose records were reviewed for assessments. Nursing staff failed to code Resident #3 had an anxiety disorder on her MDS assessment. Nursing staff failed to code Resident #42 had an anxiety disorder on his MDS assessment. This deficient practice could place residents at risk of not identifying care areas and result in residents not receiving needed care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 2 Residents (Resident #42) reviewed for PASARR services. The MDS Coordinator failed to include Resident #42 had chosen to continue with habilitative services on his Care Plan. This deficient practice could place residents at risk of not receiving services identified by the local authority.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 2 residents (Resident #4 and Resident #70) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #4 and Resident #70. This deficient practice could place newly admitted residents at risk for not receiving care and services as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 2 residents (Resident #52) reviewed for mechanical lift transfers and for 1 of 2 Residents (Resident 19) reviewed for smoking assessments. 1. Nursing staff failed to lock the wheelchair, the base of the mechanical lift and failed to widened the base of the mechanical lift when transferring Resident #52 from the wheelchair to the bed.2. The facility failed to ensure conducting Resident #19's smoking assessment quarterly. This deficient practice could place residents at risk of having avoidable falls and or accidents.2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #5 and #56) of 3 residents reviewed for incontinence care. 1. When CNA-O was providing incontinent care to Resident #5 on 02/26/2026, the CNA-O did not open the resident's labia area. 2. When CNA-J was providing incontinent care to Resident #56 on 02/26/2026 and the resident was uncircumcised, CNA-J did not pull back the foreskin of the resident's penis, cleaned the perineal area with multiple pass of one wipe. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility acted upon the pharmacist drug regimen report of any irregularities reported to the attending physician for 1 of 2 Residents (Resident #42) reviewed for gradual dose reductions. The DON failed to follow the pharmacist recommendation to change Resident #42's order for Fluoxetine from 50 mg to 40 mg administered QD per pharmacist recommendation. This deficient practice could place residents at risk for not receiving gradual dose reductions per pharmacist recommendations.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate indications for its use for 1 of 2 residents (Resident #5) reviewed for psychotropic use. Nursing staff failed to indicate an appropriate indication for Resident #5's use of Trazadone, an anti-depressant. This deficient practice could place residents at risk for the use of unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 (Resident #58 and #53) of 24 residents reviewed for medication storage. 1. Resident #58's insulin Glargine-yfgn Solos Flex Pen for diabetes had no open date, found inside A-hall nursing cart on 02/25/2026. 2. Resident #53's antifungal ointment cream was left unattended on the resident's nightstand in his room on 02/24/2026. These failures could place residents at risk of not using medications correctly and not having therapeutic effects by using old insulins.

Inspectors wroteBased on observation, interview and record review the facility failed to provide or obtain from an outside resource routine dental services for 1 of 1 Resident (Resident #2) reviewed for dental services. The facility failed to follow up and ensure the dental provider filled the prescription for a full set of dentures for Resident #42. This deficient practice could place residents at risk for not being able to chew food properly affecting their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the menus for 1 of 4 days (2/25/26) observed for meal observation. The DM failed to serve spinach for the lunch meal on 2/26/26 per menu. The DM substituted it with mixed vegetables. This deficient practice could place residents at risk for not being satisfied with the food item substitutions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Residents #18 and #61) of 24 residents reviewed, in that: 1. Resident #18's personal refrigerator located in his room was observed on 02/24/2026. There was a small plastic cup inside the refrigerator with no date and no label on the plastic cup. 2. Resident #61's personal refrigerator had unlabeled, undated food and no temperature logs. The failure could place the residents at risk for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 1 of 8 staff unlicensed staff (MA G) and 1 of 4 licensed staff (LVN H) whose records were reviewed for training The facility failed to ensure all unlicensed and licensed staff completed QAPI training. This deficient practice could place residents at risk of receiving care from nursing staff who did not understand the purpose of the QAPI program.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, failed to review the risks and benefits of bed rails, and failed to check bed rails regularly to make sure they are still installed correctly with 1 (Resident #1) of 4 residents reviewed for the use of bed rails. Resident #1 used one-quarter bed rails bilaterally for increasing bed mobility. However, the facility did not conduct safety assessments for bed rails quarterly per the facility care plan, and the bed rails were installed incorrectly as evidence by not lowering the bed rails because the bed rails were jammed. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #1) reviewed for abuse/neglect. 1. The facility failed to ensure Resident #1 was free from abuse when RN A verbally abused Resident #1 by calling her a whore and a slut.2. The facility failed to ensure Resident #1 was free from abuse when RN A physically abused by forcefully pushing the resident's wheelchair and forcefully removing her clothes on 10/4/25 around 5:20 a.m. The noncompliance was identified as PNC. The IJ began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at risk injury and psychosocial harm.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 8 residents (Resident #1) whose records were reviewed for abuse and neglect: The facility failed to ensure verbal and physical abuse that occurred on 10/4/25 at 5:20 a.m. of Resident #1 by RN A was immediately reported to the abuse coordinator. The abuse was reported to the administrator on 10/7/25. The noncompliance was identified as PNC. The IJ began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began. These deficient practices could affect residents by contributing to further abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 nurse medication cart (B hall nursing medication cart) reviewed for storage of drugs. 1. The facility failed to ensure the B hall nursing medication cart was locked. 2. The facility failed to ensure B hall nursing medication cart did not contain a narcotic blister pack with a broken seal for one of the pills and all narcotics were logged on the narcotic count sheets. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on 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, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #6) reviewed for care plans: The facility failed to ensure Resident #6's Care Plan reflected a code status of DNR. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. Record review of Resident #6's admission Record dated [DATE] revealed a [AGE] year old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #6) reviewed for administration, in that:Resident #6's OOH-DNR was signed and listed under Miscellaneous documents in the electronic medical record while her face sheet and care plan were listed as Full Code. This deficient practice could place the resident at risk of receiving care inconsistent with their wishes. Record review of Resident #6's admission Record dated [DATE] revealed a [AGE] year old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which had been furnished as well as those which were not furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 4 residents reviewed (Resident #3) for making grievances. On the morning of 8/14/2025 LVN A failed to generate a grievance report on behalf of Resident #3's complaint Resident #4 had harassed him for his personal property and both Residents had engaged in a verbal shouting match with an exchange of cursing insults between Resident #3 and Resident #4. [...]

Inspectors wroteBased on interviews and record reviews 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 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 4 residents (Resident #1) reviewed for care plans. On 8/21/2025 Resident #1 returned to the facility after hospitalization for a left arm fracture. Resident #1 was prescribed to wear a stabilization arm sling. The sling was not added to the care plan. This failure could place residents at risk for not having a care plan for care needed.

Inspectors wroteBased on observation, interview 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 three of eight residents (Residents #3, #6, #8), in the facility reviewed for infection control, in that: 1. Resident #6's oxygen tubing (oxygen machine side) was observed uncovered and on the floor. Resident #6's portable oxygen tubing was stored uncovered. 2. CNA B did not sanitize their hands between providing Resident #3 with a meal tray and then proceeding to pick up the next meal tray. 3. CNA C did not sanitize their hands between providing Resident #8 with a meal tray and then proceeding to pick up the next meal tray. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section, for two of eight residents (Residents #3, #8), in the facility reviewed for residents' rights, in that:1. CNA B did not knock nor announce themselves before entering Resident #3's room.2. CNA C did not knock nor announce themselves before entering Resident #8's room. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

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, the comprehensive person-centered care plan, the residents' goals and preferences, for one of one resident (Resident #6), in the facility reviewed for respiratory care, in that: The facility failed to ensure Resident #6's oxygen tubing was connected to the oxygen machine (on and running). This failure placed residents at risks of decreased oxygen levels, respiratory distress, falls, a decrease in the ability to perform daily tasks, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #3) of six residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to meet Resident #3's fall risk needs. The care plan listed interventions that were not in use and interventions that were in use but not listed on the care plan/Kardex. This failure could place the residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a working call light for one (Resident #3) of ten residents reviewed for working call lights consistent with the residents needs as outlined in the care plan and facility policy for the Call System. The facility failed to ensure that Resident #3 had a functional call light to call for assistance as a fall risk intervention. This failure could place the residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated this was not possible or the resident preferences indicated otherwise for 9 of 9 Residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) whose records were reviewed for nutrition staus maintenence. 1. Record review of the facility's Weights and Vitals Summary from 12/15/24-05/31/25, dated 05/06/25, reflected Residents #3, #4, #5, #8 and #9 did not have any heights documented. 2. Record review of the inspection of scale for facility weights, assessed 05/06/25 at 04:41PM, reflected the last inspection was January 20, 2023, and the next inspection was January 20, 2024, which was not done. 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to complete the Mini Nutritional Evaluation per Resident #1's care plan. This failure could affect residents and place them at risk for not having their needs and preferences met.

Inspectors wroteBased on interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete; accurately documented, readily accessible for 2 of 8 residents reviewed for care plans (Resident #2 and Resident #6). Resident #2 and Resident #6 did not have care plans accessible in their current active record. These failures could place the residents at risk of not having accurate car plans leading to Residents not recieving person centered individualized care as needed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 5 of 16 residents (Resident #9, Resident #21, Resident #36, Resident #40 and Resident #48) reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #36 after Resident #36 was suspected to be under the influence of illicit substances. Resident #9, Resident #21, Resident #36, and Resident #40 all tested positive for amphetamines. The facility did not lock and adequately supervise the back door. Further observation revealed Resident #9 and Resident #48 were smoking outside unattended. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:10 p.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 4 residents (Resident #9, Resident #25, and Resident #30) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception). 1. The facility failed to obtain signed consents for psychotropic medications for Resident #9 who was administered paliperidone palmitate extended release injectable suspension (is an atypical antipsychotic indicated for the treatment of schizophrenia) and paliperidone orally daily and required a written signature on the Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment form. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #162) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #162 on 11/20/24. This failure could affect any resident and keep them from calling for help as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 4 of 16 residents (Resident #9, Resident #36, Resident #21, and Resident #40) whose records were reviewed for abuse and neglect: The facility failed to report to the state reporting agency (HHSC) when Resident #9, #21, #36, and #40 tested positive for amphetamines during a facility investigation of possible drug use at the facility. These deficient practices could affect residents by contributing to further abuse and neglect.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 2 (Resident #29 and Resident #163) reviewed for respiratory care. 1. The facility failed to ensure Resident #29 had a oxygen sign posted on his door to alert he had an oxygen tank and concentrator in his room. 2. The facility failed to post a sign to show Resident #163 had oxygen in use. The facility failed to ensure Resident #163 had an active order for oxygen. The facility failed to ensure Resident #163 oxygen tubing was not on the floor. This deficient practice could place residents at risk for an increase in respiratory complications and make other unaware oxygen is in use.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 2 residents (Residents #30) reviewed for hospice services in that: The facility failed to maintain required hospice forms and documentation in the current hospice binders in the facility to ensure residents received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 10 residents (Resident #1, 2, 3, 4, 5, 6, and 7) reviewed for comprehensive care plans, in that: 1. The facility failed to ensure Resident #1, who needed to have one staff assist for transfer, had a care plan regarding how to transfer the resident from bed-to-chair. 2. The facility failed to ensure Resident #2, who needed to have one staff assist for transfer, had a care plan regarding now to transfer the resident from bed-to-chair. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 8 residents (Resident #8) reviewed for privacy, in that: CNA B and CNA C failed to provide privacy while providing peri-care to Resident #8 by not closing Resident #8's privacy curtain. This failure could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 10 residents (Residents #10) reviewed for incontinent care, in that: When LVN-D and CNA-E was providing bowel and bladder incontinent care to Resident #10 on 11/06/2024 at 4:24 p.m., LVN-D wiped Resident #10's buttock by only one pass with a cleaning cloth wipe as the resident had bowel movement, and LVN-D put the new brief under the resident's buttock after changing gloves, but the resident's buttock had still residual of stool. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of one out of two nursing carts (200-hall nursing cart) reviewed for storage, in that: The facility failed to ensure the 200-hall Nursing Cart was locked when left unattended. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

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 of 8 residents (Resident #8) reviewed for infection control in that: CNA B and CNA C failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns while performing peri-care for Resident #8. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with respect and dignity for 1 of 6 (Resident #21) residents reviewed for dignity in that: Facility staff stood over Resident #21 while assisting the resident with her meal in the dining area. This failure could affect residents who require assistance with activities of daily living and place them at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provided a private meeting space for residents' monthly council meetings for for 6 out of 8 residents reviewed for resident council in that: Six residents in a confidential resident group interview said they were not able to meet without interruptions from staff. This failure could place residents that participate in a resident council at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and to conduct resident council meetings without interference.

Inspectors wroteThe facility failed to have the physician's signature on the Out of Hospital Do Not Resuscitate (OOHDNR) order, for Resident # 25 which made the advanced directive invalid. This failure could affect any resident in the facility who had an OOHDNR in their chart and place them at risk of having cardiopulmonary resuscitation (CPR) performed against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Residents #38) reviewed for privacy. The facility failed to ensure Resident #38 was provided privacy during a treatment. This failure could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 1 of 10 Resident's (Resident #41) reviewed for environment. The facility failed to ensure the broken and missing tiles in the restroom and the peeling drywall in Resident #41's bedroom was repaired. These failures could affect any resident and place them at risk for not having a safe and sanitary homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable for 1 of 1 resident (Resident #20) reviewed for pressure ulcers in that: The facility failed to ensure Resident #20's offloading boots, which were used to prevent skin breakdown, were placed on the resident. This failure could place residents at risk for the development of pressure injuries.

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, the comprehensive person-centered care plan and the resident's goals and preferences, for 1 of 2 residents (Resident #20) reviewed for respiratory care. The facility to ensure Resident #20's oxygen concentrator nasal canula tubing and water reservoir was labeled with a date and the oxygen concentrator filter was missing. 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 ensure an irregularity noted by the pharmacist was acted upon for 1 (Resident #31) of 2 residents reviewed for pharmacy review in that: The licensed pharmacist made recommendations for an evaluation and a consideration of a dose reduction of Citalopram (a psychotropic medication used for depression) but there were no actions taken and no documented rationale for why actions were not taken. This failure could place resident as risk of not having their pharmacy consultations reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 4 Medication Carts (A Wing Medication Cart) reviewed for storage of drugs, in that: The A Wing Medication Cart was left unlocked, unattended and had 6 bottles of medications on top of the medication cart counter. This failure could place residents at risk of medication misuse and 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 for 1 of 1 kitchen. The facility failed to label and date food items in the kitchen walk-in refrigerator and walk-in freezer. The facility failed to ensure staff used beard net during food preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #20) reviewed for accuracy of medical records. The facility failed to accurately document Resident #20's physician's orders to apply bilateral heel boots (offloading boots) while the resident was in the bed. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

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 3 residents (Resident #38 and #116) reviewed for infection control practices, in that: 1. LVN A failed to utilize appropriate hand hygiene during the medication pass with Resident #38. 2. CNA D and LVN E failed to utilize appropriate infection control practices when entering Resident #116's room who was on transmission-based precautions. These failures could place residents at risk for infection and or a decline in health.