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Complaint Investigation

Avir At Schertz

September 17, 2025 · Schertz, TX · 3301 Fm 3009
Citations 3
CMS Rating 2/5
Beds 96
Provider ID 676301
Healthcare Facility
Avir At Schertz
Schertz, TX  ·  View full profile →
Inspection Summary

Avir at Schertz in Schertz, TX — inspection on September 17, 2025.

Found 3 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.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

with the ADON, when asked what is the resident privacy policy and how is it implemented, the ADON stated the right to their privacy, curtains for care, knock on the door and close their door.

During an interview on 09/17/2025 at 12:10 p.m., with the DON, when asked what is the resident privacy policy and how is it implemented, the DON stated the right to privacy, so staff knock on their (residents) door, pull the curtain if they are going to work with them, make sure their rights aren't violated.

During an interview on 09/17/2025 at 12:35 p.m., with the ADM, when asked what is the resident privacy policy and how is it implemented, the ADMIN stated all resident personal info is kept private, residents are covered, curtains were closed, knock on the door and announce themselves

Record review of the facility's policy titled Residents Rights, revealed the following:1.Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the residents right to: a. a dignified existence b. be treated with respect, kindness, and dignity; . t. privacy and confidentiality.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Schertz

3301 Fm 3009 Schertz, TX 78154

SUMMARY STATEMENT OF DEFICIENCIES

During an observation in Resident #6's room on 09/10/2025 at 4:00 p.m., revealed Resident #6 wore an oxygen nasal cannula (2-pronged device to deliver oxygen directly into the nose) in his nose.

The connection point (opposite from nasal prongs) of the oxygen cannula tubing was not connected to the oxygen machine/humidifier.

The oxygen machine was on, running, and set to deliver two liters per minute of oxygen through tubing.

During an interview on 09/10/2025 at 4:02 p.m. Resident #6 stated he wore oxygen with the nasal cannula all the time because if he did not, he could get short of breath.

When asked if his oxygen was on and running, Resident #6 stated yes, the oxygen was running through the tubing/prongs in his nose, but he did not feel short of breath at that time.

During an interview on 09/10/2025 at 4:10 p.m., with RN A, Resident #6's charge nurse at that time, when asked what she saw when she looked at Resident #6's portable O2 tank's tubing, RN A stated that the resident's O2 tubing was in his nose but not connected to the oxygen machine.

When asked the risks of a resident not being properly connected to an oxygen machine were RN A said, . could cause shortness of breath . woozy, dizzy. doesn't get enough air to the brain, he can get weird.

When asked who was responsible for making sure oxygen tubing was set-up properly and the tubing was connected to the machine, RN A stated, the charge nurse on duty.

Requested the facility's/a facility respiratory care policy from the Administrator on 09/10/2025 at 4:12 p.m., the policy was not provided before the survey exit on 09/17/2025.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Schertz

3301 Fm 3009 Schertz, TX 78154

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/10/2025 at 4:02 p.m. Resident #6 stated he wore oxygen with the nasal cannula all the time because if he did not, he could get short of breath.

When asked if his oxygen on and running, Resident #6 believed the oxygen tubing was connected to the machine. He stated he used the portable oxygen daily when he left his room.

During an interview with RN A on 09/10/2025 at 4:10 p.m., when asked what she saw when she looked at Resident #6's portable O2 tank's tubing, RN A stated the O2 tank had tubing that was on the floor, and the tubing should have been in a bag for infection control reasons. RN A stated the O2 tubing Resident #6 had in his nose was not connected to the oxygen machine and was on the floor.

When asked why the portable O2 tank tubing should have been in a bag, RN A stated to prevent bacteria from getting into line.

During an observation and interview on 09/10/2025 at 4:10 p.m., RN A took and replaced Resident #6's oxygen machine and portable oxygen tank tubing.

When asked why, RN A said, “Because they were contaminated and, on the floor, and anything that touched the floor needs to be replaced.”.

During an interview on 09/17/2025 at 12:10 p.m. with the DON, when asked how oxygen tubing should be stored, the DON stated “Special bags for it, with a string hang over the concentrator [oxygen machine] above the floor, on the bed.

Always in a bag when not in use.” When asked, what were the concerns with oxygen tubing being on the floor or other soiled surfaces, the DON stated, “Throw it away and replace, concern would be that it be on the floor again, solution so it doesn't go to the floor again.”.

Record review of the facility's policy titled “Standard Precautions,” revised in September 2022 the following: “5.

Resident-Care Equipment a.

Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure. contamination of clothing, and transfer of microorganisms to other residents and environments. b.

Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. c.

Single use items are properly discarded.”. 2 & 3. (Residents #3 and #8)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Schertz, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Schertz or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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