Avir at San Augustine

In the surveyor’s words

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

• Immediate jeopardy, isolatedF695Feb 14, 2025

  Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, including tracheostomy care, is provided such care consistent with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that Resident # 1 received monitoring during respiratory treatments while experiencing anxiety/nervous-type behaviors on [DATE]. Resident #1 found in distress with no pulse with ventilator partially disconnected.The resident died on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. […]

• Immediate jeopardy, isolatedF760Feb 14, 2024

  Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (Resident #246) reviewed for significant medication errors. The facility failed to ensure Resident #246 was free of significant medication errors when 11 extra doses of potassium 40 mEq were administered from [DATE] to [DATE] resulting in Resident #246 requiring hospitalization . The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by the physician. […]

• Immediate jeopardy, isolatedF770Feb 14, 2024

  Based on interview and record review the facility failed to provide or obtain laboratory services, to meet the needs of its residents for 1 of 8 residents (Resident #246) reviewed for laboratory services. The facility failed to obtain the ordered lab (comprehensive metabolic panel) for Resident #246 on [DATE] and [DATE] when the ADON failed to notify the lab of the new orders and note the lab orders on the 24-hour report on [DATE], resulting in Resident #246 requiring hospitalization for critically high potassium level of 7.6 on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. […]

• No harm, potential for more than minimal, patternF759May 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. The facility had a medication error rate of 21.62%, based on 8 errors out of 37 opportunities, involving 3 of 5 (Resident #16, Resident #19 and Resident #39) residents and 1 of 2 nurses (LVN B) reviewed for medication errors. LVN B failed to administer scheduled medications on 5/12/2026 to Resident #16 and Resident #39 and failed administer the correct dosage of medications on 5/12/2026 to Resident #16 and Resident #19.These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications.Findings Include:Resident #16Record review of Resident #16's facility face sheet, dated 5/12/2026, indicated Resident #16 was an… […]

• No harm, potential for more than minimal, patternF880May 13, 2026

  Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN B, the Treatment Nurse, and CNA D) reviewed for infection control.The facility failed to ensure the LVN B sanitized or washed hands between glove changes when colostomy care was provided to Resident #8 on 5/11/2026.The facility failed to ensure the Treatment Nurse sanitized or washed hands between glove changes when wound care was provided to Resident #8 on 5/11/2026.The facility failed to ensure CNA D washed or sanitized hands while passing lunch trays on 5/11/2026 on… […]