Avir At Grand Saline

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

proposed change. During an interview on 10/28/2025 at 03:05 PM, Charge Nurse C said nurses should notify the resident and his or her responsible party of new physician's orders and changes in physician orders. She said there were times when the resident or responsible party did not agree to orders or changes. Charge Nurse C said it was the resident's right to disagree with the doctor. She said she would let

the doctor or nurse practitioner know if a resident or responsible party had a concern or did not agree with any orders. During an interview on 10/29/2025 at 11:30 AM, the DON said the nurses were responsible for notifying residents and responsible parties of changes in care and treatment. She said it was important for

the residents and responsible parties to be informed and given the opportunity to participate in the decision-making process. The DON said she and the ADON reviewed new physician's orders daily in the morning meeting. She said they missed seeing that Resident #3 and the responsible party were not notified of the changes to the insulin dosing and blood sugar testing. A record review of the facility's policy titled Change in a Resident's Condition or Status dated Revised April 2025 indicated the following: Policy StatementOur facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition or status (e.g., changes in level of care, billing/payments, resident rights, etc).5.Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.6.

Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform

the resident of any changes in his/her medical care or nursing treatments.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Grand Saline

1638 Vz Cr 1803 Grand Saline, TX 75140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553

significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Grand Saline

1638 Vz Cr 1803 Grand Saline, TX 75140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure a comprehensive assessment was completed, using

the CMS-specified process, within the regulatory time frames for 1 of 3 residents (Resident #4) reviewed for comprehensive assessments. The facility failed to complete a comprehensive MDS assessment for Resident #4 within 14 days of admission to the facility. This failure could place new residents at risk of delays in assessments and the residents' care plans not accurately reflecting their current needs. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE REDACTED] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record

review of an incomplete admission MDS with an ARD date of 10/20/2005 indicated Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Further review of the MDS indicated sections A (identification Information, F (Preferences for Routine & Activities), GG (Functional Abilities), J (Health Conditions), O (Special Treatments, Procedures, and Programs), Q (Participation in Assessment and Goal Setting) and V (Care Area Assessment Summary) were not completed. Record

review of Section Z indicated the MDS had not been signed as completed as of 10/29/2025. Record review of Resident #4's MDS history indicated he was admitted to the facility on [DATE REDACTED], had an admission assessment in progress and was 2 days overdue. During an interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she did not know why the MDS had not been completed. She said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said she had been the MDS Coordinator for less than a year and was still slow at completing the MDS assessments. She said the Regional MDS Consultant had been helping her, but the Consultant had other buildings to help also. The MDS Coordinator said Resident #4's admission MDS assessment should have been completed by 14 days

after admission which was 10/27/2025. Record review of the RAI Version 3.0 Manual: Section 2.2 indicated

the following: Policy Interpretation and Implementation1.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.2.admission Assessment - The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:.c. the resident has been admitted to this facility and was discharged return not anticipated and did not return within 30 days of discharge.The admission Assessment (Comprehensive) must be completed by the 14th day of the resident's stay (admission date + 13 = completion date).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Grand Saline

1638 Vz Cr 1803 Grand Saline, TX 75140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

#3's principal diagnosis of COPD and co-existing diagnosis of emphysema were not addressed in the care plan. The revised care plan indicated there were no goals or interventions to address identified risks of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). Record review of scanned documents, progress notes and social worker notes for Resident #3 from 02/27/2025 - 05/02/2025 did not indicate Resident #3 and/or representative had been informed of the development of a care plan.

During an interview on 10/27/2025 at 11:25 AM, Resident #3's representative said she had not been consulted about or included in the care planning process for Resident #3. During an interview on 10/28/2025 at 03:10 PM, the DON said she had been at the facility for about 4 months. The DON said she,

the MDS Coordinator, and Social Worker shared in the care planning process. She said neither she nor the Social Worker were employed at the facility during Resident #3's stay at the facility and could not explain why Resident #3's revised care plan did not address the principal diagnosis for which Resident #3 was re-admitted to the facility. She said she did not know why Resident #3 and the representative had not been given a copy of Resident #3's care plan. 3. Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE REDACTED] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record review of an incomplete admission MDS with an ARD date of 10/20/2005 noted Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Record review of Resident #4's electronic medical records revealed Resident #4's had an undated baseline care plan that was incomplete and had not been signed by Resident #4 or Resident #4's representative. A record review of a paper copy of a baseline care plan dated 10/14/2025 for Resident #4 indicated the blank baseline care plan was printed, manually completed, and signed and reviewed with Resident #4's responsible party on 10/16/2025. The completed and signed baseline care plan was not in

the electronic health record. During an interview on 10/29/2025 at 03:15 PM, the DON said she found Resident #2's and Resident #4's manually completed baseline care plans in a stack of papers in medical records. She said it took her a while to find them. She said the care plans had not been scanned into the computer and therefore, were not a part of the electronic health records and were not available or communicated to the nursing staff. The DON said the baseline care plan could not be updated to reflect the residents' changing needs if it was not in the computer to begin with. The DON said it would be better to complete the baseline care plans in the electronic chart to ensure the nursing staff had access to baseline care plans. A record review of the facility's policy titled Care Plans - Baseline Care Plan dated Revised March 2024 indicated the following: A baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1.The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include.but not limited to the following: a.Initial goals based

on admission orders and discussion with the resident/representative;, .b.Physician ordersc.Dietary orders,d.Therapy servicese.Social services; andf.PASRR recommendations, if applicable 2.The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Grand Saline

1638 Vz Cr 1803 Grand Saline, TX 75140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 set forth 483.10(c)(3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to ensure a comprehensive person-centered care plan was developed and completed within 21 days of admission to the facility for Resident #2. This failure could place residents at risk of a delay in receiving care and services to meet medical and nursing needs. The findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #2 was an [AGE] year-old female who admitted to the facility 10/06/2025 with diagnoses which included Alzheimer's disease, dementia, aortic stenosis (a condition where the aortic valve in the heart becomes narrowed, restricting blood flow from the heart to the rest of the body), and osteoporosis. Review of an MDS dated [DATE REDACTED] revealed Resident #2 had a BIMS score of 6 indicating her cognition was severely impaired. Record review of Resident #2's medical records indicated a comprehensive care plan had not been completed. During an

interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she, the DON, and the ADON shared responsibility for developing and implementing the care plans. She said for new admissions, the comprehensive care plan was to be done within 7 days of the completion of the comprehensive assessment and no more than 21 days after admission. She said that since the comprehensive MDS had not been completed, the comprehensive care plan had not been completed. She said Resident #2's comprehensive care plan should have been completed no later than 10/27/2025. The MDS Coordinator said she was working on getting caught up. The MDS Coordinator said the facility used RAI Version 3.0 Manual as the guide for completing MDS assessments and care plans. During an interview on 10/29/2025 at 03:15 PM, the DON said she, the ADON, and the Social Worker were new to the facility and were working on processes to get caught up and organized. She said she was not aware Resident #2's comprehensive care plan had not been completed. Review of CMS's RAI Version 3.0 Manual Section 2.2 indicated the Care Plan Completion Date must be dated by the end of the 7th calendar day following the completion date of the admission Comprehensive Assessment and can be no later than day 21 (admission date +21 = Comprehensive Care Plan due date). A review of the facility's policy titled Care Plans, Comprehensive Person-Centered and dated 2001 with a revision date of March 2022 indicated the following: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in status), and no more than 21 days after admission.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Grand Saline

1638 Vz Cr 1803 Grand Saline, TX 75140

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

AM-9:45 AM with nurses, CNAs, and MAs from both shifts (6AM-6PM and 6PM-6AM) (CNA F, CNA G, CNA H, CNA J, CNA K, NA L, LVN M, NA N, MA O, NA P, CNA Q, CNA R, CNA S, CNA T, CNA U, NA V, NA W) indicated they said they had been trained on abuse and neglect, residents at risk for elopement, facility staff response if they saw a resident leave unaccompanied, facility staff response to door alarms sounding, the purple binder containing lists of residents at risk for elopement, and doing a census check of all residents listed in the purple binder. They said if they saw a resident exit the facility they should go out and try to get them to come back inside. They said if the door alarms sounded, they should check the panel to identify which door they should check and then go outside and do a perimeter check around the whole facility and if they did not find anyone, they should report it to their charge nurse or DON. They said they should also use the purple binder to identify residents with Wanderguards and go to their rooms or around

the facility to make sure they were all present in the facility.

Event ID:

Facility ID:

If continuation sheet