Avir at San Angelo

In the surveyor’s words

From the most serious findings on record at Avir at San Angelo, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 22, 2023

  Based on observations, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. […]

• Immediate jeopardy, patternF600Jul 28, 2023

  Based on interviews and record review the facility failed to ensure residents had the right to be free from abuse for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse. 1) The facility failed to ensure a safe environment free from abuse for Resident #1. On 07/22/23 at 11:15p.m, CNA A was observed by LVN B cleaning Resident #1's bleeding ear lobe and denied not knowing what happened. Resident #1 was transferred to the hospital and found to have multiple injuries including left ear laceration, left shoulder abrasion, hematoma on the right and left abdomen, hematoma on the left leg, skin tear on the left forearm and bruise on the foreskin of his penis. […]

• Immediate jeopardy, patternF609Jul 28, 2023

  Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 2 of 4 residents (Resident #1 and #2) reviewed for neglect. 1) LVN B failed to report physical abuse of Resident #1 after witnessing CNA A 's rough actions with the resident during incontinent. […]

• Immediate jeopardy, patternF610Jul 28, 2023

  Based on observations, interview and record review revealed the facility failed to, in response to allegations of abuse, thoroughly investigate the alleged abuse for one (Residents #1) of 4 residents reviewed for resident abuse. 1) The facility failed to thoroughly investigate an incident of physical abuse of Resident #1 when LVN B observed rough action by CNA A while providing incontinent care to o Resident #1. 2) The facility failed to thoroughly investigate an incident of physical abuse of Resident #2 by CNA A. On 07/23/23 at 10:00a.m, ADM was informed by LVNB and RP of video recording of physical abuse of Resident #2. […]

• Immediate jeopardy, isolatedF600Aug 22, 2026

  Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Residents #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from sexual abuse on 7/20/2026 when CNA W confessed to the local police department that he forced Resident #1 to perform oral sex on him on a date.An Immediate Jeopardy (IJ) situation was identified on 08/20/26. While the IJ was removed on 08/22/26, the facility remained out of compliance at a scope of isolation with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. […]