Avir at Kerrville

In the surveyor’s words

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

• Immediate jeopardy, patternF656Jul 1, 2024

  Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Resident #1, #3, #4) of 4 residents reviewed for care plans. 1. Facility failed to develop a person-centered care plan that addressed Resident #1's risk for fall to with interventions to prevent further injury when he was admitted to the facility on [DATE] with a broken neck from a fall at home and when he had a fall at the facility on 6/05/2024 (date of admission), 6/09/2024, two falls on 6/12/2024 and a fall on… […]

• Immediate jeopardy, isolatedF678Apr 6, 2025

  Based on interviews, and record reviews the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (#1) residents in that: Resident #1 was administered CPR, 2 compressions which caused Resident #1 to moan in pain, by LVN A after found unresponsive. Resident #1 was a DNR. Resident #1 had an OOH-DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6 PM. While the IJ was removed on [DATE] at 1:26 PM. […]

• Immediate jeopardy, isolatedF689Jul 1, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision, in that; The facility failed to ensure Resident #1 was supervised while ambulating and had interventions in place to prevent falls. Resident #1 who was admitted with a significant history of falls, had 5 documented falls at the facility from admission to discharge, 6/05/2024 date of admission, 6/09/2024, 6/12/2024 x 2 and 6/24/2024 when he fell during the night and suffered a subdural hematoma (a pool of blood between the brain and its outermost covering) and required a hospital stay in ICU. […]

• Actual harm, patternF760Dec 12, 2025

  Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 3 residents (Resident #1) reviewed for drug administration in that:Resident #1 was administered one tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) twice a day from 11/14/2025 to 11/26/2025. The physician order was 1 tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) once a day.The noncompliance was identified as PNC. […]

• No harm, potential for more than minimal, widespreadF640May 8, 2024

  Based on interviews and record reviews the facility failed to, within 14 days after a facility completes a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the admission assessment for 3 of 3 residents (Residents #101, #102, and #103) reviewed for MDS assessments. The facility failed to transmit the MDS withing 14 days of assessment for Resident's #101, #102, and #103. These failures placed residents at risk by not providing resident specific information for payment and quality measure purposes. The findings included: 1. […]