Avir At Mineola
Avir at Mineola in Mineola, TX — inspection on August 29, 2025.
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
During an interview on 8/29/25 at 10:55 a.m. the DON said she expected staff to notify the physician of changes in condition including skin conditions, swelling, or weeping.
During an interview attempt on 8/29/25 at 12:16 p.m. LVN B did not answer the phone and her voicemail was full.
During an interview on 8/29/25 at 2:06 p.m. the DON the importance of notifying the physician of a change in condition was to get the appropriate diagnosis and treatment for a resident.
Record review of the facility's Change in a Resident's Condition or Status policy last revised 6/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status.
The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.
675668 08/29/2025
Avir at Mineola 320 Greenville Highway Mineola, TX 75773
expected all medications including as needed medications to be documented in the EMR.
The DON
medication and the medications effectiveness.
Record review of the facility's Medication
prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.A.
Preparation.4.
Five Rights- right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .5.
The medication administration record (MAR) is always employed during medication administration.B.
Administration.2.
Medications are administered in accordance with written orders of the prescriber.
675668 08/29/2025
Avir at Mineola 320 Greenville Highway Mineola, TX 75773
the resident, his or her attending physician, healthcare provider, and the resident representative of
of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental
emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.
675668 08/29/2025
Avir at Mineola 320 Greenville Highway Mineola, TX 75773
The facility failed to ensure CNA E had a current nurse aide certification while employed at the facility and actively providing care for residents from [DATE] through [DATE]. CNA E certificate expired on [DATE].
This failure placed residents at risk for decreased quality of care.
Findings included:
Record review of CNA E's employee file indicated her nurse aide certification was issued on [DATE] and would expire on [DATE].
The employee file indicated CNA E's initial nurse aide certification was issued on [DATE].
The employee file indicated she applied to the facility on [DATE] and was available for work on [DATE].
The employee application indicated her nurse aide certification would expire on [DATE].
Record review of CNA E's time sheets from [DATE] through [DATE] indicated other than 4 days of PTO, she had taken CNA E had worked her normal full-time shift at the facility.
During an interview on [DATE] at 11:50 a.m. the BOM said CNA E's nurse aide certification expired on [DATE].
The BOM said when LVN C brought it to her attention that CNA E had an expired nurse aide certification she pulled the certification in TULIP and saw it had been renewed on [DATE].
The BOM said she did not know how many if any days CNA E had worked with an expired nurse aide certification or why CNA E did not renew her nurse aide certification by [DATE].
The BOM said she did not know how LVN C was aware of CNA E's expired nurse aide certification or what date she was notified on.
During an interview on [DATE] at 12:35 p.m. the Administrator said he had not been aware CNA E had been working with an expired nurse aide certification until she told them.
The Administrator said the facility and corporate do monitor for expired or expiring license and certifications, but CNA E had not showed up on any of their lists.
The Administrator said CNA E told them she had not renewed her certification because she did not know how to work TULIP.
During an interview on [DATE] at 12:41 p.m. CNA E said her nurse aide certification was expired for several months without her realizing it because she thought the facility would renew it for her like her previous facility did. CNA E said when she realized her nurse aide certification was expired due to her working nights, she had not gone up to the facility to have them assist her with the renewal paperwork. CNA E said there was really no excuse for her nurse aide certification being expired for so long.
During an interview on [DATE] at 2:25 p.m. the Administrator said the facility did not have a policy regarding nurse aide certification renewal/expirations/registry.
The Administrator said the facility did have an annual employee checklist that was supposed to be completed on all employees annually.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.