Avir At Kingsland

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

A and other staff were in- serviced regarding the importance of triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes. The DON stated staff were observed and reviewed by the DON and ADON daily and issues if any were discussed during the daily staff meeting.

During an interview on 09/08/25 at 12:30pm the ADM stated, on 09/13/25 in the afternoon the RP of Resident #1 met him at his office. He stated the RP was visibly upset and complained about the competency of LVN A . The ADM stated , the RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident . The ADM said, though LVN A had not done her job in a timely manner , Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am , Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing , recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in placeRecord review of facility in service revealed on 09/15/25 an in service conducted on the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report after every shift.'

Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment.Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas:a. Resident Rights .m. Identification of changes in condition .Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

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

11/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Kingsland

3727 W Ranch Rd 1431 Kingsland, TX 78639

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 0684 Level of Harm - Actual harm Residents Affected - Few

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

upset and complained about the competency of LVN A . The ADM stated, the RP told him to terminate LVN

A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident. The ADM said, though LVN A had not done her job in a timely manner, Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am, Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing, recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report

in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in place Record review of facility in service revealed on 09/15/25 an in service conducted on

the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report

after every shift'. Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment. 1. Competency is a measurable pattern of knowledge and skills abilities , behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . 2. All nursing staff must meet specific competency requirements of their respective licensure ad certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) following areas: .Resident rights, person centered care, communication, Basic nursing skills, medication management, infection control , Skin, and wound care.Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

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

11/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Kingsland

3727 W Ranch Rd 1431 Kingsland, TX 78639

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

monitored to ensure the carts are locked. He said the administrative staff monitor through observation. Said that he did not have a good explanation as to why the medication cart and treatment cart were unlocked.

Record review of Medication Labeling and Storage Policy dated 2/2023, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Event ID:

Facility ID:

If continuation sheet