Avir at Cotulla

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Jan 8, 2026

  Based on interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, of the 6-month review period for (25 of 184 days), reviewed for RN coverage.The facility failed to ensure the facility maintained the required RN coverage for 25 days between July 2025 to December 2025.The dates are: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.Findings included:Record review of CMS CASPER Report (a confidential, that analyzes internal data to measure the quality of patient care) reflected the… […]

• No harm, potential for more than minimal, patternF641Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 9 residents (Resident #6, Resident #41, and Resident #52) who were reviewed for resident assessments. 1.The facility failed to document Resident #6's lack of use of scheduled pain medication on the quarterly MDS assessment. 2.The facility failed to document Resident #41's diagnosis of anxiety on the quarterly MDS assessment. 3. The facility failed to document Resident #52's use of an antidepressant on the quarterly MDS assessment. […]

• No harm, potential for more than minimal, patternF812Jan 8, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to date items after receiving/opening them located in the kitchen pantry. 2. The facility failed to take temperatures for both breakfast and lunch meals on 01/05/2026. This deficient practice could place residents at risk for food borne illness.The findings include: Observation on 01/06/2026 at 10:00 a.m., of the kitchen pantry revealed 1 box of food thickener with no date, 1 bag of lime gelatin, opened, in a Ziploc bag, which was sealed, with no date, 1 container of chicken flavored base with no date, and 1 container of beef flavored base with no date. […]

• No harm, potential for more than minimal, patternF558Sep 8, 2023

  Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 3 of 23 (Residents #4, #22, #36) residents reviewed for call lights: 1. Resident # 4's call light was connected to the light string hanging behind her bed on the opposite side of the bed she was sitting on and not within reach. 2. Resident #2's call light was attached to the privacy curtain, out of reach. 3. Resident #36's call light was not within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. […]

• No harm, potential for more than minimal, patternF726Sep 8, 2023

  Based on observation, interviews, and record review, the facility failed to ensure nursing staff was able to demonstrate competency in skills and techniques for 1 of 2 (RN C) RNs observed during medication pass. The facility failed to prevent RN C from following: 1. Established Infection Control Procedures while passing medications to Resident #5 and Resident #10. 2. HIPAA privacy requirements to lock and close the laptop while passing medications to Resident #7. 3. The procedure to lock the medication cart before walking away during the medication pass. 4. […]