Avir At Kingsland

During an interview and observation on 06/26/26 at 8:36 AM with Resident #50, the HK entered the room with laundry without knocking on the door. Resident #50 stated that staff knock most of the time, but occasionally staff don't knock. Resident #50 stated that it bothered her when staff do not knock on the door.

During an interview on 05/28/2026 at 3:32 PM with RN G, she stated that staff were expected to knock on residents' doors before entering the room or announce their arrival.

She stated that that was a resident's rights issue.

She stated HK could have walked into the room while Resident #50 was receiving care.

She stated that she had not seen any staff not knocking on residents' doors.

She stated that if she saw staff not knocking on residents' doors, she would have reminded them to do so.

During an interview on 05/28/2026 at 4:05 PM with the DON, she stated that all staff should knock on the door when entering the room.

She stated that she had not seen any staff not knocking on residents' doors.

She stated that if she saw staff not knocking on the door, then she would correct them.

She stated it was a privacy and dignity issue for the residents when staff did not knock on residents' doors.

She stated that if staff did not knock, a resident could have been receiving care.

During an interview on 05/28/2026 4:20 PM with the ADM. He stated that it was his expectations for staff to knock on residents' doors He stated that staff were trained on knocking on doors before going in.

Record review of the facility's Resident Rights policy updated on February 2021 reflected:Residents are to be treated with respect, kindness, and dignity.

676035 05/28/2026

Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639

Review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/26/2026.

She was admitted for rehab services following a fall and surgical repair of a fracture to her left hip.

Diagnoses information included: Displaced fracture of the base of neck of left femur with routine healing, epistaxis (nose bleeds), Cachexia (complex metabolic condition leading to muscle and or fat loss), Restless leg syndrome, lack of coordination, history of fall with injury to head, idiopathic gout (painful inflammatory arthritis caused by excess uric acid in the blood), Dementia unspecified severity without behavior disturbances, hearing loss, hypertension (high blood pressure), Paroxysmal Atrial Fibrillation (heart arrythmia), Chronic heart failure, acute kidney failure, history of falling.Review of Resident #1's physician orders revealed orders for Trazodone HCl oral tablet (50 MG, give 1 tablet by mouth at bedtime for insomnia) and Quetiapine Fumarate oral tablet (25 MG, give 1 tablet by mouth at bedtime for depression).

Orders were scheduled to start on 3/31/2026 and were both signed for approval by the MD. Resident #1 does not have a diagnosis of insomnia or depression listed. In a telephone interview on 5/28/2026 at 4:40 PM with the MD, he stated that he did quite a bit of psych medication for dementia behaviors. He stated the process for orders is he gives the orders verbally or he will enter the orders himself, and depending if they are on hospice care, then the orders have to come through hospice. He stated that the consent is based on nursing home policy and the facility is responsible for obtaining signed consent. He stated that consent is only needed for certain psych medications. He agreed that medications like Seroquel, trazadone and Depakote needed consent.

When other medications such as Buspar, Fluoxetine he stated, A lot of these medications you are listing are prescribed by psych services and they would get consent.

When asked about prescribing Resident #1 Trazadone for Insomnia and Quetiapine for depression, he stated, I would never treat depression with Seroquel.

Seroquel is a medication also known as Quetiapine in generic form. He stated that if the order for Quetiapine stated it was for depression, then the order was entered wrong.

He stated that he does review the verbal orders placed in point click care after they have been entered and checks them for accuracy before signing. He stated he may have missed the error in the order. He did not explain why the medication was prescribed without a matching diagnosis. He stated that he needed to go back to work and ended the interview incomplete.

Review of the facility's Resident Rights policy revised 02/2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the residents' right to-Be free from chemical restraints not required to treat the residents' symptoms. -Be informed of and participate in his or her care planning and treatment

Findings included:Review of daily HR total employee hours report (lists total clocked in hours worked daily by staff across all departments) provided by the ADM for the following dates: 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25 reflected zero RN hours were registered as worked.

During an interview on 05/28/26 at 01:24 PM with the DON, she stated she was not the DON during the infraction dates found with no RN coverage and could not speak as to why there was no RN coverage since she started her time at the facility February of 2026.

She stated the facility was required to have 8 consecutive hours every day 7 days a week of RN coverage and that being without an RN is unacceptable for her.

The DON stated that having an RN in the facility gave an extra layer of professionalism and resident care.

During an interview on 05/28/26 at 02:49 PM with the ADM, he stated he did not know why there were no RN hours on the reports for the infraction dates 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 or 12/28/25 since he only started as administrator March of 2026. He stated it was the expectation that they would have the minimum 8 RN hours required daily. He stated it was ultimately the responsibility of the administrator to ensure staffing coverage.

He stated a potential negative outcome of not having daily RN hours would be not having the clinical oversight that you need. He stated he attempted to look for anything that indicated an RN worked on those dates but could not find documentation that indicated an RN was in the facility for the 8 hours required.

The ADM stated there was not a facility policy specific to RN hours, but that they follow state and federal guidelines.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

676035 05/28/2026

Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639

The facility failed to provide meal

to provide palatable food served at an appetizing temperature or taste to Residents #7, #13, and #28.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Findings include:

During an interview on 5/26/26 at 8:30 a.m., Resident #7 said the food at the facility was not good.

She stated that she rarely eats the food in the facility because it isn't good.

She stated that she had to get the backup meal, which is mainly salads.

She stated that she has reported the food being a problem.

During an interview on 5/26/26 at 8:35 a.m., Resident #13 said the food at the facility was not good.

She stated that he rarely ate the food in the facility because it was not good.

She stated that she would have to get the backup meal, which was mainly salads.

During an interview on 5/26/26 at 10:05 a.m., Resident #28 said he liked living in the facility. He stated that he got the same food over and over again. He stated that there were times when the food was unappealing. He stated that he ate the food anyway, because he did not want to eat the sandwich. He stated that often the food did not taste good.An observation on 05/27/2026 12:50 PM lunch tray revealed it was served to the residents on 5-27-2026.

The lunch consisted of black beans, corn, carnitas, and a tortilla.

The carnitas did not look appealing and appeared to have been boiled.

The Carnitas had little flavor and tasted like it was boiled.

During an interview on 05/28/2026 at 11:15 AM, CK A stated that she had cooked the food that was given to her.

She was shown a picture of the food that had been cooked on 5/27/2026.

She stated that the food was carnitas.

She stated that she had not been working the day that food was cooked.

She stated that the food cooked on 5/27/2026 did not look appealing and she would not have eaten it.

She stated that residents could have lost weight if they did not eat the food.

During an interview on 05/28/2026 11:15 AM, with the ADM, a picture of the food that was prepared for residents on 5/27/2026 was shown to him. He stated that the food did not look good. He stated that he would not eat that food unless someone made him. He stated that they were in the process of getting a different food provider. He stated that unappealing food could lead to weight loss. On 5-28-2026 at 2:30 PM ADM stated there was no policy for food palatability.

676035 05/28/2026

Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639

that residents could get sick and spread gems.

The DM stated that everyone should be cleaning the

to knock on the door when entering the room.

She stated that she had not seen any staff not knocking

them.

She stated it was a privacy and dignity issue for the residents when staff did not knock on residents' doors.

She stated that if a staff member did not knock, a resident could have been getting care.

She stated that staff were expected to sanitize their hands in between passing trays to each resident.

She stated that when this was not done, it was an infection control issue.

She stated that she had not seen any staff not sanitizing their hands in between residents.

She stated if she saw staff not doing that, she would have stopped them and reminded them to do it.

She stated that she would have had staff retrained on infection control.An Interview on 05/28/2026 4:20 PM with the ADM.

The ADM stated that staff were expected to regularly check for dates in the kitchen, and ensure there is no out-of-date food.

She stated that all staff are expected to sanitize their hands in between each resident when passing out to residents.

She stated all staff were supposed to be cleaning the kitchen.

She stated that if these are not followed, residents could get sick,

Record review of the facility's Food and Storage policy updated December 2021 reflected, Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.All food preparation items should be sanitized before use.

Kitchen should be cleaned regularly.

676035 05/28/2026

Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639