Avir At Bay City
AVIR AT BAY CITY in BAY CITY, TX — inspection on February 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
actions that can be measured.
interview and record the facility failed to review and revised the person-centered comprehensive care
failed to update Resident #22's care plan to reflect the status of Resident #22's NPO status.
This failure could place residents at risk of not receiving the appropriate care and interventions they need.
Record review of Resident #22's face sheet dated 2/26/2026 revealed a [AGE] year old male admitted to the facility originally on 8/7/2024 and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive movement disorder of the nervous system that worsens over time), Dysphagia Oropharyngeal phase (the inability to swallow food or drink), and Unspecified Dementia (a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities).
Record review of Resident #22's Order Summary dated 2/26/2026 revealed a dietary order of a NPO diet with a start date of 2/18/2026. Resident #22 had a current order of Jevity 1.5 ml at 69 ml per hour via a gastrostomy tube (a feeding tube that goes through the skin of the belly into the stomach for feedings) stationary pump.
Record review of Resident #22's most recent comprehensive care plan obtained 2/25/2026 revealed that Resident #22 was at risk for aspiration (when food, liquid, or other material accidentally gets into your windpipe and lungs) and listed interventions that included monitoring oral intake and reporting to the MD as needed for signs and symptoms of aspiration.
Additionally, interventions included to encourage Resident #22's intake of nutritional supplements between meals.
Record review of a nursing progress note dated 2/17/2026 revealed that Resident #22 was readmitted to facility and was NPO.
Interview with the MDS nurse on 2/25/2026 at 11:59 am revealed she was responsible for all resident care plans.
The MDS nurse stated that Resident #22's care plan did not accurately reflect the care needed that Resident #22 required.
The MDS nurse stated that the entire facility required new care plans due to the new software system and that it was a heavy load.
The MDS nurse stated that Resident #22's care plan did not reflect the recent change to NPO that was given after Resident #22's most recent hospitalization.
The MDS stated that the risk of not having a care plan that reflected the current needs of the residents could lead to missed services and interventions that could lead to a resident not receiving the appropriate care they need.
Interview with ADON on 2/26/2026 at 9:15 am revealed that she was not responsible for care plans and stated the MDS nurse was responsible for creating and updating care plans.
Interview with the DON on 2/26/2026 at 1:01 pm revealed that she did not know too much about care plans nor does she create or revise them.
The DON stated the MDS nurse was responsible for updating care plans to reflect any significant changes in the care of the residents.
Record review of the facility policy statement, undated, and titled Comprehensive Assessments revealed in part. assessments are used to develop, review and revise the resident's comprehensive care plan.
The facility policy statement did not specifically address the revision of comprehensive care plans.
Review of the facility policy and procedure titled Medication Labeling and Storage revised February 2023 revealed: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.
The medication label includes, at a minimum: . expiration date, when applicable.
455643 02/26/2026
Avir at Bay City 700 12th St Bay City, TX 77414
#39's electronic medical record did not reveal documented evidence of Resident #39's refusal of the
diagnoses that included non-traumatic intracerebral hemorrhage (a condition where bleeding occurs
severe stage of kidney disease where the kidneys can no longer filter waste effectively), Type 2 Diabetes Mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), and Epilepsy (brain disorder caused by abnormal electrical activity in the brain).
Record review of Resident #5's Comprehensive MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment.
Section O of Resident #5's Comprehensive MDS dated [DATE] indicated that Resident #5 was not up to date with the pneumococcal vaccination and had declined the offer of the Pneumococcal vaccine.
Record review of Resident #5's electronic medical record did not reveal documented evidence of Resident #5's refusal of the pneumococcal vaccine Interview with the ADON on 2/26/2026 at 9:32 am revealed she was the infection preventionist for the facility and was responsible for immunization compliance along with the DON.
The ADON stated that a resident's immunization status should be listed in the immunization tab of the electronic record but sometimes it was in the notes section.
The ADON stated that all residents were offered immunizations for influenza, pneumococcal, and covid on admission.
The ADON stated that the facility had an influenza vaccination event that ran from October 2025 to November 2025.
The ADON stated that she was working on a pneumococcal vaccination event for the residents.
The ADON states the events were done because the facility didn't stock the influenza or pneumococcal vaccines, but the facility could order the vaccines as needed.
When asked if there was a specific number that was needed to have a vaccination event occur, the ADON did not provide a number.
The ADON was asked to provide documentation of offering, administration or refusal of the influenza and pneumococcal vaccines for Residents#12, Resident #7, Resident #39, Resident #2, and Resident# 5, but stated she was unable to locate the information.
The ADON stated the facility went through a change of software in April of 2025 and resident data crossed over completely.
When asked how she monitored immunization compliance for the residents, the ADON did not have an answer.
The ADON stated she knew this was an area that needed attention.
When asked what the risk was associated with not assessing immunization compliance, the ADON stated the resident could be vaccinated twice for the same illness, the residents could get sick with a preventable disease, or the resident could receive vaccinations that were contraindicated.
Interview with the DON on 2/26/2026 at 11:41 am revealed the DON stated there was a facility wide influenza event in October and November of 2025.
The DON stated that not all the influenza immunization records had been uploaded into Point Click Care {PCC.} which is the facility's electronic record software system.
The DON stated that she was aware that some residents needed pneumococcal vaccinations and there was a plan to get a mass vaccination event conducted at the facility.
The DON stated immunization documentation was an area that she was aware of that needed attention and was working on getting immunizations uploaded and updated.
The DON stated she was in the process of getting a pneumococcal vaccination event scheduled.
The DON stated that the facility began using a new software program and it had affected how immunization dates and refusals were placed into the new system.
The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations.
Record review of facility policy statement, undated and titled Influenza, Prevention and Control of Seasonal revealed in part. all residents and staff are offered the vaccine prior to the onset of the influenza season.
Record review of facility policy titled Pneumococcal Vaccine dated 2001 revealed in part. all residents are offered pneumococcal vaccines to aid in the preventing pneumonia/pneumococcal infections.
455643 02/26/2026
Avir at Bay City 700 12th St Bay City, TX 77414
a specific number of residents.
When asked what the risk were associated with not assessing
have received vaccinations that were contraindicated.Interview with the DON on 2/26/2026 at 1:01
stated that the system change from Matrix to PCC was causing a problem with documentation of covid vaccine administrations and refusals.
The DON stated that sometimes residents were already immunized against Covid prior to admission, and but records were not consistently updated in the electronic medical record.
The DON stated it was a work in progress.
The DON stated the risk of not having up to date immunization records for residents could possibly lead to preventable illness, or unnecessary vaccinations .
Record review of facility policy titled Coronavirus Disease (COVID-19) -Vaccination of Residents dated 2001 revised May 2023, revealed in part.The resident's medical record includes documentation that indicates at a minimum.signed consent.#2 prior vaccination or refusal.
455643 02/26/2026
Avir at Bay City 700 12th St Bay City, TX 77414