Avir At Kaufman

During an observation on 01/08/2026 at 8:17 AM, the damaged trim had been removed leaving the interior wall exposed.

The exposed area was unfinished and did not have replacement trim or protective covering installed.

During an interview on 01/05/2026 at 11:25 AM, Resident #15 stated she was scared she would get injured by the missing trim that was jagged when the resident is propelling in the wheelchair.

During interview on 01/08/2026 at 12:44 PM, the facility maintenance director acknowledged awareness of the damaged trim and stated the trim had been removed, however the area had not been restored to a finished residential condition at the time of observation.

Reported it has been that way a month or more.

Yesterday I cut the hanging trim off so now it has to be fixed.

The Maintenance director could not recall who reported the hanging trim to him.

During interview on 01/08/2026 at 1:44 PM, CNA E reported that she had noticed the trim coming off the wall in Resident #15's room. CNA E stated Resident #15's wheelchair would catch the hanging trim when moving passed the trim. CNA E said she had verbally reported the broken trim to the maintenance director several weeks ago but could not recall an exact date or time.

During an interview with the ADON on 01/08 2026 at 1:57 PM, said all staff are responsible for ensuring rooms are safe and have a homelike appearance.

The ADON stated the loose trim was a tripping hazard.

During an interview with the administrator on 01/08/2026 at 2:19 PM, the Administrator stated he was not aware of the missing trim; however, the maintenance director was responsible for all repairs.

The facility used a computerized tracking system and the staff was instructed to report all needed repairs to the maintenance director.

Record review of Homelike Environment policy revision date February 2021 revealed the policy statement of residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Clean, sanitary and orderly environment.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

be reevaluated for services.

The Director of MDS said the purpose of Form 1012 was to alert the local

Level 1 was completed correctly.

The Director of MDS said it was important for the residents to be

interview on 01/08/26 at 2:11 p.m., the Administrator said the MDS was responsible for the PASRR Level 1 Screening, and he was the overseer. He said he expected the MDS Coordinator to fill out the PASRR Level 1 Screening accurately. He said the PL1 form was completed to see if the residents would be positive or negative for mental health. He said if they were positive, then the residents would qualify for services that could benefit them.

Record review of the facility's undated policy titled PASRR dated 07/09/25, indicated, Purpose: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs.

Procedure: 1. admission Process: C).

Preadmission happens when a person comes from the community (psychiatric hospital, home, group home, jail, assisted living, etc.).

This includes anywhere other than a medical acute care hospital or another nursing facility.

The person, coming from the community, with a PASRR.

Level 1 that indicates suspicion of IDD, and/or mental illness, must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility.

This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission. D).

Negative indicates the person has a negative PL1 screening, and is not suspected of having an intellectual disability, developmental disability, and/or mental illness.2.

Screening Process: A).

Level I Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission. B).

Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted.

This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

hours

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

verified that she had given her a breathing treatment on 01/03/26 and said the nebulizer treatments

disciplines should work together to complete a resident's care plan, but the DON and nurse

care.

Record review of the facility policy titled Care planning, dated 12/2024, indicated Policy Statement: The interdisciplinary team is responsible for the development of resident care plans.

Policy Interpretation and Implementation:1.

Resident care plans are developed according to the timeframes and criteria established by S483.21. 2.

Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).4.

The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

2011 indicated, Policy Statement: All personnel must learn methods of fire prevention and must report

Whoever identifies a fire hazard or other conditions that could develop into a fire hazard must report

Items: a.

Smoke only in designated areas. b. Do not put cigarettes in trash cans.#4.

All personnel must report observations of: A. accumulation of trash and rubbish; B. unusual odors or conditions; C. smoking in unauthorized areas; F. any unusual incidents; H. violation of fire safety rules. #5.

The safety coordinator will be responsible for the prompt investigation of such conditions.

Hazardous conditions must be corrected as soon as practical.

Appropriate departments, such as building engineers/maintenance, etc., shall be responsible for the prompt correction of electrical, plumbing, or structural hazards.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

The facility failed to ensure CNA G and CNA H properly cleaned the perineal/genital areas for Resident #15 during incontinent care.

These failures could place residents at risk for urinary tract infections.During a record review of a face sheet dated 01/08/2026 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke because a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain).

During a record review of Resident #15's quarterly MDS assessment dated [DATE] after a recent readmission to the facility revealed resident #15 toileting hygiene ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement was chart coded as 01: Dependent.

Always incontinence of urinary and bowel.

During a record review of Resident #15's care plan dated 09/18/2025 it was revealed she was care planned for activities of daily living (ADLs). Resident #15 also was care planned to keep skin clean and dry as possible to minimize skin exposure to moisture due to occasional moisture associated with skin damage to buttocks and skin folds.

Record review of physician progress notes dated 12/27/2025 indicated Resident #15 has a past medical history of urinary tract infections.

During an observation on 01/06/2026 at 9:39 AM, Resident #15 was provided incontinent care by CNAs G and H.

The incontinent care revealed CNAs G and H used the same visibly soiled gloves throughout the entire care provided for Resident #15 with a bowel movement. CNA G and CNA H failed to change their gloves and failed to perform hand hygiene before, during and after the incontinent care.

During an interview on 01/06/2026 at 9:50 AM, CNA G stated that she failed to change gloves and perform hand hygiene during Resident #15's perineal care provided by her and one other staff member (CNA H). CNA G acknowledged Resident #15 was on enhanced barrier precautions. CNA G said proper perineal care was provided to residents to prevent urinary infections.

During an interview on 01/06/2026 at 9:55 AM, CNA H revealed it was her first day on the job and she had not completed incontinent care skills check-off.

During an interview on 01/08/2026 at 2:06 PM, the ADON revealed that nursing administration are responsible for conducting check-off prior to allowing nursing staff to work independently.

The ADON reported they have hand washing audits quarterly.

The ADON stated the risk of incorrect incontinent care can cause urinary tract infections.

During an interview on 01/08/2026 at 2:24 PM, the Administrator reported nursing staff was responsible for performing incontinent care.

The Administrator said procedure check offs were done on hire and annually. He said he expected the DON and ADON to ensure skills are performed properly and skills are checked off prior to working independently.

The Administrator reported residents are at risk for infection when incontinent care is not performed correctly.

The Administrator reported the ADON and DON perform hand washing audit and annual skill check off to ensure compliance.

During a record review on 01/08/2026 at 10:26 PM of Perineal Care policy dated February 2018 revealed the purpose of this procedure is to provide cleanliness and comfort to the residents, to prevent infections and skin irritation, and to observe the resident's skin condition.Wash hands.

Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely.

Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens / adult brief.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

During an observation on 01/08/26 at 2:30 p.m., revealed Resident #15's facemask was observed on the bedside table without being bagged and dated.

During an interview on 01/05/26 at 2:40 p.m., LVN F revealed Resident #15 had recently received a nebulizer treatment and LVN F failed to return the facemask to the storage bag, stating she had been busy. LVN F acknowledged the purpose of bagging the facemask is to prevent contamination and bacteria spread.

During an interview on 01/05/26 at 2:45 p.m., Resident #15 said she had just had a nebulizing treatment and required staff assistance with applying and storing the facemask.

During an interview on 01/08/26 at 2:10 p.m., the ADON stated nursing staff are expected to check nebulizer equipment during rounds that occur every two hours and ensure nebulizer facemasks are properly stored.

The ADON reported nebulizer supplies are changed weekly and stated proper storage is required to prevent contamination.

During an interview on 01/08/26 at 2:25 p.m., the Administrator stated all supplies are expected to be properly secured and stored to prevent illness.

The Administrator stated department heads conduct daily safety rounds and nursing staff are responsible for ensuring supplies are properly stored after treatment administration.

Record review of the facility's policy titled Oxygen Administration, revised date of October 2010, indicated, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration.

Preparation: # 1.

Verify that there is a physician's order for this procedure.

Review the physician's orders and facility protocol for oxygen administration.

Equipment and Supplies:.#4. No Smoking/Oxygen in Use signs.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

During an interview on 01/08/2026 at 2:10 PM, the ADON stated medications are to be secured in the medication cart, during treatment nursing staff are expected to monitor resident rooms for medications during rounds.

The ADON acknowledged residents are at risk of harm when medications or creams are left at bedside.

During an interview on 01/08/2026 at 2:27 PM, the Administrator confirmed department heads conduct daily safety rounds and stated medications and creams are not permitted to be stored at the bedside due to safety concerns of consumption.

During a record review of an order summary dated 01/08/2026 indicated Resident #15 had an active order for oral care every shift beginning 11/13/2025 with no end date and an order for diet of nothing by mouth, there was not an order for Vaseline or petroleum jelly.

Record review of the facility's policy titled Medication Labeling and Storage last revised on 02/2023, indicated. the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

Only authorized personnel have access to keys. 1.

Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

Medication Storage 2.

The nursing staff is responsible for maintaining medication storage.4.

Compartments (including, but not limited to. refrigerators, carts) containing medications and biologicals are locked when not in use. or carts used to transport such items are not left unattended if open or otherwise potentially available to others.Medication Labeling 2.

The medication label includes, at a minimum: b. prescribed dose. f. route administration. 12.

The nursing staff must inform the pharmacy of any changes in physician orders for a medication.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

The facility failed to ensure

failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Findings included: During a confidential resident group meeting 9 residents stated the food could be warmer.

During an interview on 01/05/26 at 12:09 p.m., Resident #32 stated the food was not too good. Resident #32 would not go into detail on how the food was not good.

During an observation and interview on 01/06/26 at 12:44 p.m., lunch tray was sampled by the Dietary Manager and 4 surveyors.

The sample tray consisted of beef stroganoff which was lukewarm, a mushy texture, and overpowered garlic flavor; green beans were cold and bland; and the overall appearance was soggy and greasy.

The Dietary Manager stated the beef stroganoff could have been warmer and the noodles were overdone; green beans were bland, below room temperature and the food could have been separated more.

During an interview on 01/08/26 at 9:15 a.m., CNA D stated residents had stated the food was cold. CNA D stated she was unable to recall the resident's name. CNA D stated when they complained about the food being cold, she would reheat their food in the employee breakroom. CNA D stated she did not take the temp of the food after reheating and has never been told too. CNA D stated she was told by staff that she could reheat their food but unable to recall the staff name. CNA D stated she did not report the complaints to anyone. CNA D stated residents not eating their food could potentially cause weight loss.

During an interview on 01/08/26 at 9:21 a.m., CNA E stated residents randomly complained about the food not being good overall. CNA E stated she was unable to recall the resident's name. CNA E stated she would offer the residents an alternative. CNA E stated all food complaints would be reported to the dietary staff. CNA E stated residents not eating their food could potentially cause weight loss.

During an interview on 01/08/26 at 10:21 a.m., RN B stated at times residents do complain about the food being cold or bland. RN B stated there was not a specific resident she could recall. RN B stated she would offer the residents an alternative and report to the dietary staff. RN B stated it was important to ensure food was palatable and had an appetizing temperature to maintain their adequate weight and proper nutrition for healing.

During an interview on 01/08/26 at 1:01 p.m., the Dietary Manager stated she had not had any complaints regarding food being cold or tasting bland in the last several months.

The Dietary Manager stated if food complaints were brought to her an alternative would be offered.

The Dietary Manager stated she monitored meal service daily, including sampling trays a few times a week, especially a new meal.

The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss.

During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he expected food to be at the appropriate temperature and seasoned for palatability.

The Administrator stated he has not had any complaints about food being cold or bland.

The Administrator stated the Dietary Manager was responsible for monitoring and overseeing meal service.

The Administrator stated he has not experienced a test tray that was not palatable including temperature.

The Administrator stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss.

Record review of the facility's policy titled, Food and Nutrition Services revised 10/2017 reflected. each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional. needs.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

sanitization purposes.

The Administrator stated eggs should be pasteurized.

The Administrator stated

The Administrator stated these failures could potentially put residents at risk for cross

and Service revised 11/2022 reflected.

Food and nutrition services employees prepare, distribute, and service food in a manner that completed with safe food handling practices. 2.

Potential Hazardous Food.

Unpasteurized eggs.

Food Preparation, Cooking and Holding Time/Temperatures.5.

Food thermometers used to check food temperatures. 9.

Previously cooked food was reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds before for hot service.

Record review of the facility's policy titled, Food Receiving and Storage revised 11/2022 reflected.

Food shall be received and stored in a manner that complies with safe food handling practices.

Dry Food Storage. 4.

Dry foods that are stored in bins are removed from original packaging, labeled and dated .

Record review of the undated facility's policy titled, Cleaning Dishes/Dish Machine .

All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use.

The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing.

Procedure (1).

Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

Findings included: 1.

Record review of Resident #15's face sheet, dated 01/08/26, reflected Resident #15 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support).

Record review of Resident #15's quarterly MDS assessment, dated 10/16/25, reflected Resident #15 rarely/never made herself understood, and sometimes understood others. Resident #15's BIMS score was 7, which indicated his cognition was severely impaired. Resident #15 was dependent with eating and had a feeding tube while a resident of the facility and within the last 7 days.

Record review of Resident #15's comprehensive care plan, edited on 10/06/25, reflected Resident #15 required the use of a gastrostomy tube for nutrition s/p CVA with dysphagia (difficulty swallowing).

The care plan interventions included observe peg tube/g-tube site for s/sx of infection/irritation, NPO, and oral hygiene at least every shift. 2.

Record review of Resident #36's face sheet, dated 01/08/26, reflected Resident #36 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dependence of renal dialysis (treatment that filters waste, toxins, and extra fluid from your blood when your kidneys fail), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and shortness of breath.

Record review of Resident #36's quarterly MDS assessment, dated 10/21/25, reflected Resident #36 made herself understood, and usually understood others. Resident #36 BIMS score was a 9, which indicated her cognition was moderately impaired.

The assessment indicated Resident #36 was receiving oxygen therapy and dialysis.

Record review of Resident #36's comprehensive care plan, edited 09/24/25, reflected Resident #36 required PRN oxygen therapy related to COPD.

The care plan interventions included administer oxygen via nasal canula (PRN): O2 at 1-4 LPM.

The care plan reflected Resident #36 required dialysis due to dialysis.

The care plan interventions included hemodialysis performed on Monday, Wednesday and Friday.

During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he was responsible for completing and updating the facility assessment.

The Administrator stated those things that were mentioned above should have been reflected in the assessment.

The Administrator stated it was important to update the facility assessment to prevent the proper focus on the residents that needs particular care.

The Administrator stated the risk associated with not updating the assessment was residents not receiving the proper care.

During an interview on 01/08/26 at 2:11 p.m., the RNC stated there was not a policy and procedure regarding facility assessment.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

infections to other personnel, residents.

Indications for hand hygiene (1) Hand Hygiene is indicated: b.

Record review of the facility's policy titled Standard Precautions last revised on 09/2022, reflected.

or conformed infection status.

Standard precautions include the following practices: 5.

Resident-Care Equipment. b. reuseable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

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Avir at Kaufman 3001 S Houston St Kaufman, TX 75142

were safe to smoke.

She said that since the smoking assessment was not being done, it could place

management was the overseer. He said smoking assessments was done for the safety of the

10/22, indicated, This facility shall establish and maintain safe resident smoking practices. #8 The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the smoking assessment. #9 A residents' ability to smoke or chew tobacco safely will be reevaluated quarterly, upon a significant change, and as determined by the staff.