Avir at Sherman

Inspectors wroteBased on interview and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for one (Resident #1) of 1 resident reviewed for PASRR services. The facility failed to ensure a complete and accurate PASRR Nursing Facility Specialized Services (NFSS) request form for OT and PT was submitted into the Texas Medicaid & Healthcare Partnership (TMHP) portal within 20 business days after the date of the Interdisciplinary Team (IDT) meeting to facilitate services for Resident #1 as agreed upon in the meeting. This failure placed residents at risk of not receiving specialized PASRR services that would enhance their highest level of functioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for six of six residents (Resident #1, #2, #3, #4, #5, #6) observed during medication pass. 1. The Facility failed to ensure MA A followed the facility's policy on administering medications for Resident #1, Resident #2 and Resident #3 by prefilling the resident's morning medication prior to the administration time on 02/18/26. 2. The Facility failed to ensure MA B followed the facility policy on administering controlled medications for Resident #4, Resident #5, and Resident #6 by prefilling the resident's medication prior to the administration time on 02/18/26. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for one of three residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility and disruption in the continuity of care.

Inspectors wroteBased on interviews, and record review, the facility failed to inform the resident's physician, when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in condition was discovered for Resident #1. The physician was not made aware of the change in mental status that occurred on 11/27/2025. Resident #1 was sent to the hospital for evaluation at the request of the responsible party. [...]

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Record review (PASRR) Level II determination and the PASRR evaluation report for 1 of 4 residents (Resident #2) reviewed for PASRR assessments. The facility failed to submit the Nursing Facility Specialized Services (NFSS) form request by the specific deadline for Resident #2 for therapy services. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for two of five shower rooms (shower rooms on 100 and 200 halls), 4 of 4 linen storage areas (3 blue carts (100, 200, and 300 halls) and 1 linens closet) reviewed for environment and 16 of 18 residents (Resident #14, Resident #19, Resident #58, and Resident #65) and 12 confidential residents reviewed for clean linens which included towels, and sheets. 1. The facility failed to ensure the shower rooms were cleaned throughout the day, kept orderly, and maintained in a sanitary and comfortable condition for resident use. 2. The facility failed to ensure there were clean washcloths for Residents #19, #58, and #65 on 06/04/25 and 06/05/25 for bathing. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Residents #227, #46, #32) of 18 residents reviewed for comprehensive care plans. 1. The facility failed to create a care plan that reflected Resident #227's preference for only female staff to provide her personal care. 2. The facility failed to create a care plan that reflected Resident #46's preference for only female staff except for CNA T (a male CNA) to care for her. 3. The facility failed to create a care plan that reflected Resident #32's highly impaired hearing, vision, and aphasia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 7.89 %, based on 3 errors of 38 opportunities, which involved two of five residents (Residents #19 and #26) and two of five staff (MA C and MA D) reviewed for medication errors, in that: 1. MA C administered Vitamin B-12 1000 mcg instead of Vitamin B-12 100 mcg and failed to administer duloxetine 60 mg to Resident #19's on 06/04/25 as ordered by the physician. 2. MA D failed to administer Resident #26's folic acid 1 mg on 06/04/25 as ordered by the physician. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food and drink that was palatable for one meal (Lunch 6/3/25) observed for 3 out of 18 residents (Resident #227, Resident #56 and Resident #177) for food palatability and food form. The facility failed to provide palatable lunch meal on 6/3/25 for 3 residents. This failure could place residents at risk of decline in nutrition status, loss of appetite, and decreased intake placing them at risk for unplanned weight loss.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer were dated or labeled. 2. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 6/3/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation of freezer in the kitchen and interview with Dietary Manager on 06/03/25 beginning at 9:16 am: -clear opened to the air plastic bag with about 25 corn dogs, in an unsecured box labeled corn dogs. [...]

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 diseases and infections for four (Resident #70, Resident #66, Resident #19, and Resident #61) of seven residents observed for infection control. 1. The facility failed to ensure LVN A used the required PPE for Resident #70, who was on enhanced barrier precautions due to her venous access device, while administering resident IV antibiotics on 06/04/25. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 18 residents (Resident #227) reviewed for nutrition: The facility did not ensure Resident #227's diet was consistent with physician's order on 5/8/25 for Diabetic Diet. This failure could place the resident at risk for weight loss and further decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for one (Residents #177) of one resident reviewed for dialysis. The facility nursing staff failed to document and assess Resident #177's returning vital signs, access site, and mental status after Resident #177 returned from dialysis treatment on 05/27/25, 05/31/25, and 06/03/25. This failure places residents in the facility who received dialysis at risk of not receiving proper care and coordination of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of two (Resident #43) reviewed for behavioral health services. The facility failed to ensure Resident #43 received his ongoing psychiatric services. Resident #43's last psychiatric appointment provided was on 01/29/25. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of five residents (Resident #70) reviewed for pharmacy services. The facility failed to ensure LVN A followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #70. These failures placed residents at risk of not receiving full dosage of medication.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 residents (Resident #71) reviewed for medication storage. The facility failed to ensure Resident #71 did not have a medication named BioFreeze (a topical analgesic) at Resident #71's bedside table on 06/03/25. This failure could place residents at risk of having access to medications, resulting in harm, misuse of medication, drug diversions, and adverse reactions to medications due to improper storage.

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 1 (Resident#3) of 7 residents reviewed for ADLs. The facility failed to ensure Resident #3's nails were cleaned and trimmed on 04/16/2025. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #1 and Resident #2) of 4 residents reviewed for infection control. 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and #2 on 04/16/2025. This failure could place residents at-risk of cross contamination which could result in infections or illness.

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 2 (Resident #13, Resident #40) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had her fingernails cleaned and trimmed. 2- Resident #40 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

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 for the facility's only kitchen: 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were covered and dated. 2. The facility failed to ensure [NAME] A used appropriate hair restraint in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (200 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure the 200 Hall medication cart had: 1- 1 insulin pen for Resident #175 with an expired opened date. 2- 1 insulin pen for Resident #17 with an expired opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #24) observed for infection control. Facility failed to ensure CNA D performed hand hygiene while providing incontinence care to Resident # 24. This failure could place the residents at risk for infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 4 out of 5 residents (#1, #3, #4, and #5) reviewed for ADL care. The facility failed to provide timely incontinence care every two hours or as needed for Resident #1 on 4/22/24. The facility failed to provide timely incontinence care on a regular basis for residents #1, #3, #4, and #5. This failure could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative of the discharge with the reasons for the discharge in writing, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and failed to record the reasons for the discharge in the resident's medical record for 1 (Residents #1) of 3 residents reviewed for transfer and discharge requirements. 1. The facility failed to initiate a 30-day discharge notice to Resident #1 and ombudsman on 08/28/23 when facility made decision based on inability to meet resident's needs not to readmit Resident #1 to the facility from the hospital. 2. The facility failed to have written documentation of facility's decision to not readmit Resident #1 from the hospital in resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 3 residents reviewed for transfer/discharge requirements. The facility failed to establish and follow a policy to address Resident #1's request to return to the facility after a hospitalization when facility initiated discharge on [DATE]. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Resident #47, and #56). The facility did not implement their abuse/neglect policy related to reporting and investigating allegations within time frames required by federal requirements when 2 residents were involved in altercations with other residents (Residents #47 and #56). This failure could place residents in the facility at risk for abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 24 hours after the allegation was made for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Residents #47, and #56). The facility failed to timely report an allegation of resident abuse after the allegation was made to the administrator. This failure could affect all residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all alleged violations involving abuse and neglect were thoroughly investigated, and failed to report the results of all investigations to HHSC within 5 working days of the incident for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation Residents #47, and #56). The facility failed to properly investigate allegations of abuse or neglect for Residents #47, and #56. This failure could place residents at risk of allegations not being investigated.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident 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 three (Residents #26, #44 and #52) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #26's contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in her legs and preference to stay in bed were care planned for Resident #26. 2. The facility failed to ensure Resident #44's lower extremities impairment was care planned for Resident #44. 3. [...]

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 3 (Resident #13, Resident #45, Resident #54) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had his fingernails trimmed. 2- Resident #45 had his fingernails trimmed and cleaned. 3- Resident #54 had his fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for t of six Residents (Resident #60 and #62) reviewed for medication administration errors. Facility failed to ensure the medications were administered per the physician orders for Resident #60 and #62. 28 medications were administered, two of the medications administered were late. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication carts (300 hall medication aide cart) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #17) observed for infection control. Facility failed to ensure CNA E perform hand hygiene while providing incontinence care to Resident # 17. This failure could place the residents at risk for infection.