Avir at Kennedale

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to report violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to the State Survey Agency for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report an injury of unknown source to HHSC when Resident #1 sustained a dislocated left shoulder on 04/19/26. This failure could place the residents at risk of injuries not being thoroughly investigated and potential neglect.

Inspectors wroteBased on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 13 of 60 days reviewed during a look back period from 02/07/26 to 04/05/26 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 02/08/26, 02/14/26, 02/15/26, 02/21/26, 02/22/26, 02/29/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/22/26, 03/28/26, 03/29/26. This failure could place residents at risk of not having their nursing and medical needs met and improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #2) reviewed for feeding tubes. LVN C failed to follow physician orders and added water to Resident #2's g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications). formula prior to administering her feeding. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 resident (Resident #2) reviewed for pharmaceutical services. LVN C failed to follow the facility policy when she mixed and crushed Resident #2's medications and administered them via g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications). This failure placed residents at risk of not receiving the therapeutic dosages of their medications, gastric upset, pain, and symptomatic changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control practices. CNA A failed to perform hand hygiene and glove changes while providing Resident #1 with incontinence care and a shower. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment, in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for foot care. The facility failed to follow physician orders for Resident #1's wound care on her toe. This failure could place residents with wounds to their feet at risk of not receiving proper foot care and developing infections in their wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 resident (Resident #1) reviewed for pressure ulcers. The facility failed to ensure Resident #1 received wound care according to physician orders on 11/05/25, 11/21/25, 11/24/25 and 11/27/25. The failure placed residents at risk for pressure ulcer deterioration and infection.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #24) of 6 residents reviewed for care plans. The facility failed to develop a person-centered comprehensive care plan for Resident #24, who was at high risk for elopement and who had exit-seeking behaviors. Resident #24 eloped from the facility on 08/08/25, she was found near an apartment complex on a busy street next to the facility by a passerby and brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (Resident #24) reviewed for supervision. The facility failed to ensure Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby, who brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly council meetings for 8 of 8 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 residents (Resident #6 and #7) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Resident #6, who received nutrition via tube feeding and had unavoidable weight loss, was weighed weekly as ordered by the physician. 2. The facility failed to ensure Resident #7, who had unplanned weight gain, was weighed weekly as ordered by the physician. This failure could place the residents at risk of weight changes going unnoticed leading to a worsening of their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 34 days (04/20/25, 06/01/25, 06/21/25, 7/19/25 and 07/27/25) reviewed during a look back period from 04/01/25 to 07/31/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 04/20/25, 06/01/25, 06/21/25, 7/19/25 and 07/27/25. This failure could place residents at risk for not having their nursing and medical needs met and improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menus met the nutritional needs of residents in accordance with the established national guidelines and were followed for 1 of 3 meals (lunch meal 08/06/25) observed. [NAME] D failed to follow the menu when preparing the pureed lunch meal on 08/06/25. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed Cilantro Lime Chicken as a pudding consistency for residents who required pureed diets during the lunch meal on 08/06/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plan of care for 1 of 6 residents (Resident #32) reviewed for quarterly care plans. The facility failed to invite Resident #32 and responsible parties with 4 quarterly care plan conference meetings for the last 12 months. Resident #32's last care plan meeting was dated 08/07/24. This failure could place residents at risk of not receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to implement their policy on reporting an incident involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby who brought her back to the facility. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to report an incident to HHSC involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that is consistent with the discharge rights set forth at 483.15(b) as applicable and involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan for 1 of 3 residents (Resident #24) reviewed for discharges. The facility failed to involve Resident #24's POA in the discharge plan prior to Resident #24 being transferred to a different facility on 08/11/25. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #24) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #24. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #32) of 6 residents for care plan revisions. The facility failed to review and revise Resident #32's comprehensive care plan after the MDS assessment was completed on 06/25/25. Resident #32's last care plan meeting was dated 08/07/24. This failure could affect residents and could result in resident's needs not being met. Record review of Resident #32's face sheet, dated 08/07/25, reflected the resident was a [AGE] year-old female with an admission date of 08/03/23 and returned 03/08/25. Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected her diagnoses included hypertension (high blood pressure), dementia, cognitive communication deficit, and depression. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 16 residents (Resident #26) on one hall reviewed for storage of medications. Resident #26 had 1 tablet sucralfate at her bed side unsupervised on 08/05/25. This failure could place residents at risk of consuming unsafe medications.

Inspectors wroteBased on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24) reviewed during a look back period from 04/09/24 to 07/15/24 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24. This failure could place residents at risk for not having their nursing and medical needs met and improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and were labeled in accordance with currently accepted professional principles for 1 (Resident #134) of 9 residents reviewed for pharmacy services. LVN D failed to put her initials, date, and time on Resident #134's IV medication bag and tubing when she administered the IV antibiotic, Meropenem. These failures could place residents at risk for medication error and delay in medication administration.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format by electronically submitting to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 8 (11/16/24, 11/17/24, 11/21/24, 11/23/24, 11/27/24, 11/28/24, 11/30/24, and 12/31/24) of 8 days reviewed. The facility failed to submit accurate licensed nurse hours for 11/16/24, 11/17/24, 11/21/24, 11/23/24, 11/27/24, 11/28/24, 11/30/24, and 12/31/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure Resident #1's off-loading boot, which was used to prevent skin breakdown, was placed on the resident. This failure could place residents at risk for the development of pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 four (Residents #1, #2, #3, and #4) of six residents and two (CNA B and CNA C) out of five staff in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #1 and #2 were separated after Resident #2 tested positive for COVID on 10/19/23, and Resident #1 did not. 2. The facility failed to ensure Residents #3 and #4 were separated after Resident #4 tested positive for COVID on 10/19/23, and Resident #3 did not. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to ensure: - the dishmachine was working properly and did not have to been run mulitple times to reach 120 degrees F; - the Dietary Manager was aware of the dishmachine was a sanitizing dishmachine and not a high temperature dishmachine; - Dishwasher Aide B was documenting actual dishmachine tempteratures; and - food stored in the pantry was properly stored, labeled and dated. This failure could place residents at risk for food contamination and food borne illness.