Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Cotulla during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours per day, 7 days a week, during multiple periods in the review window. CMS CASPER and the facility RN schedule showed no RN hours on several dates, and the Administrator stated the prior DON had been released and the facility had difficulty finding RN applicants due to the location and population. The facility policy required an RN to provide services at least 8 hours every 24 hours, 7 days a week.
MDS assessments did not accurately capture key resident information for three residents. One resident was coded as receiving scheduled pain medication despite having only PRN pain orders, another resident’s anxiety diagnosis was omitted from the MDS despite documentation in the chart and psych notes, and a third resident’s antidepressant use was not recorded even though Trazodone was ordered and administered. The MDS nurse confirmed at least one of the assessments was not reflecting the resident’s medication use accurately.
Undated food items were found in the kitchen pantry, including food thickener, opened lime gelatin, chicken flavored base, and beef flavored base. Food temperature records also showed no temperatures documented for breakfast or lunch entrees, and the Dietary manager, DON, and [NAME] confirmed that food temperatures were supposed to be taken before meals and that products were supposed to be dated when received or opened.
Controlled substance records were not properly reconciled for Med Cart 2 when an LPN handed off the cart key before lunch. Although a sample inventory matched the pills on hand, the comprehensive controlled medication reconciliation log was not signed at the handoff, and the DON stated staff had not been counting controlled meds during these key transfers. Facility policy required the oncoming and off-going nurses to count together and document discrepancies.
Unlabeled and undated food items were found in a resident’s personal refrigerator, including opened mayonnaise and mustard brought in by the resident and family. The resident said staff were checking the fridge temperature but had not been labeling the items. CNA, LVN, and DON interviews confirmed staff were responsible for checking personal fridges and that items should be labeled and dated, and the facility policy required food brought in by family or visitors to be labeled with the resident’s name, item, and use-by date.
Failure to Use EBP Gown During G-Tube Medication Administration: An LVN administered meds through a resident’s G tube while wearing gloves but no protective gown, despite the resident having an active EBP order and care plan for G-tube use. The resident had MS, dementia, PVD, depression, and epilepsy, and facility policy identified feeding tube care as a high-contact activity requiring gown and glove use. The DON and ADON stated staff were expected to wear gowns and gloves for care involving EBP.
Two CNAs did not follow infection control protocols while providing incontinent care to a resident with severe cognitive impairment and total care needs. The CNAs failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces and before starting care, and one CNA did not sanitize hands between glove changes, despite facility policy and prior competency checks.
A facility failed to provide appropriate treatment for a resident with a left hand contracture. Despite the resident's history of Parkinson's disease and cerebral infarction, and requiring substantial assistance with eating, no preventative measures were in place for the contracture. Observations and staff interviews confirmed the absence of assistive devices, and the resident expressed difficulty in managing the contracture. Facility documentation and care plans did not address the issue, and specialists provided no specific recommendations.
The facility failed to transmit accurate and complete MDS data for four residents, as required by OBRA regulations. The MDS Coordinator admitted that the errors were due to oversight, resulting in assessments being returned with warnings or remaining in process. The facility's policy mandates timely completion and transmission of MDS assessments, which was not adhered to in these cases.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week during the 6-month review period. Record review showed no RN coverage for 25 days between July 2025 and December 2025, including 7/3/2025 through 7/7/2025, 8/4/2025 through 8/8/2025, 9/8/2025 through 9/12/2025, 10/9/2025 through 10/12/2025, 11/10/2025 through 11/12/2025, and 12/16/2025 through 12/18/2025. The facility’s RN schedule confirmed that the required RN coverage was not maintained on those dates. The CMS CASPER report also reflected prompts for no RN hours for FY 4th Quarter 2025 for the same dates. During interview on 1/7/2026 at 2:09 p.m., the Administrator stated the previous DON had been released from employment and that, during the hiring process, there were no RN applicants because of the location and population, making it difficult to attract enough qualified candidates. The facility policy titled Staffing, Sufficient, and Competent Nursing, revised 08/2022, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
MDS Assessments Did Not Accurately Reflect Pain Medication, Anxiety, or Antidepressant Use
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected residents’ current status for 3 of 9 residents reviewed. For Resident #6, the quarterly MDS documented that the resident received scheduled pain medication in the last five days, even though the order summary showed only as-needed pain medications and no scheduled pain medication order. Resident #6’s record also showed diagnoses including multiple sclerosis, dementia, peripheral vascular disease, depression, and epilepsy, and the care plan identified the resident as at risk for discomfort or pain related to MS. For Resident #41, the quarterly MDS did not include anxiety in the active diagnoses section even though the resident’s record documented anxiety as a diagnosis. The resident’s chart included diagnoses of neurocognitive disorder with Lewy bodies, depression, anxiety, hypothyroidism, and type 2 diabetes mellitus. The record also showed psychiatric services for anxiety, depression, and dementia, with a psychiatric assessment listing generalized anxiety disorder and depressive disorder. The resident’s October 2025 MAR documented anxiety during shift behavior monitoring. For Resident #52, the quarterly MDS did not document the resident’s use of an antidepressant even though the order summary showed Trazodone 150 mg twice daily and the MARs showed the resident received it during the look-back period. The resident’s diagnoses included hemiplegia, mood disorder, dementia, anxiety disorder, major depressive disorder, and schizoaffective disorder. During interview, the MDS nurse confirmed the resident was taking Trazodone and stated the MDS did not reflect the antidepressant use but should have.
Undated Food Items and Missing Meal Temperature Logs
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. On 01/06/2026 at 10:00 a.m., observation of the kitchen pantry found 1 box of food thickener with no date, 1 opened bag of lime gelatin in a sealed Ziploc bag with no date, 1 container of chicken flavored base with no date, and 1 container of beef flavored base with no date. Record review of the facility policy, Food Storage, dated 2023, stated that all containers or storage bags must be legible and accurately labeled and dated. Record review of the Food Temperature Chart for 01/04/2026 to 01/10/2026 showed that under breakfast and lunch for Monday, 01/05/2026, no temperatures were recorded for any of the entrees served. During interview, the Dietary manager stated food temperatures should be taken as soon as food items were put on the steam table, for every meal, and every day, and stated the cook and dietary manager were responsible for dating products as they got food deliveries. The Dietary manager also stated they were not aware of any food borne illness outbreaks within the facility. The DON stated they were not aware of any food borne illness outbreaks since being employed at the facility, and the [NAME] stated they were supposed to take the temperature of all foods before every meal.
Controlled Substance Reconciliation Not Documented During Cart Handoff
Penalty
Summary
The facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for Med Cart 2. During observation of the cart, a sample of controlled medications was inventoried with LVN A and no discrepancies were found between the individual controlled substance logs and the pills remaining in the blister packs. However, record review of the comprehensive controlled medication reconciliation log showed that the log had not been signed when LVN B gave control of her key to Med Cart 2 to LVN A before lunch. During interview, LVN A stated it was important to count and document controlled medications when taking supervision of a medication cart so the count would be correct and any missing pill would be identified. The DON stated staff responsible for medication carts had never counted the controlled medications when handing off their key to another staff member before lunch, and that moving forward staff were expected to count and document controlled medications when relinquishing their key. LVN B also stated that when handing over the medication cart key before lunch, it was important to count and document the controlled medications because medications could go missing. The facility policy stated controlled substance inventory is monitored and reconciled to identify loss or potential diversion, and that the nurse coming on duty and the nurse going off duty make the count together and document any discrepancies.
Unlabeled and Undated Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary storage, handling, and consumption of residents’ food items in one resident room refrigerator. In room [ROOM NUMBER]-A, the personal refrigerator contained two bottles of mayonnaise and one bottle of mustard that had been previously opened and were unlabeled and undated, with expiration dates that were not legible or hard to obtain. The resident stated the food items were brought in by himself and family, and also stated staff had not been labeling the items in the personal refrigerator, although staff had been checking the refrigerator temperature. During interviews, CNA C stated housekeeping usually checks residents’ refrigerators and that the items should be labeled and dated, and confirmed the items in room [ROOM NUMBER]-A were unlabeled and undated. LVN D stated nurses and CNAs were responsible for checking residents’ personal refrigerators nightly for expiration dates and dating opened items, and confirmed the items were unlabeled and undated. The DON stated housekeeping checks residents’ personal refrigerators for temperatures and to see if anything needs to be thrown away, and stated staff would not know whose items were whose if they were not labeled. The facility policy, Food Brought in by Family/Visitors, stated food left with the resident to consume later is to be labeled and stored so it is clearly distinguishable from facility-prepared food, and perishable foods are to be stored in resealable containers in a refrigerator with containers labeled with the resident’s name, the item, and the use by date.
Failure to Use EBP Gown During G-Tube Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections for one resident who received medication through a PEG tube. Resident #6 was a [AGE]-year-old female with diagnoses including multiple sclerosis, dementia, peripheral vascular disease, depression, and epilepsy. Her record showed a feeding tube in use, an active order for Enhanced Barrier Precautions for the G tube, and a care plan stating she required Enhanced Barrier Precautions related to use of the G tube for nutritional, hydration, and medication needs, with an intervention to follow facility policy. During observation of G-tube medication administration, LVN B wore gloves but did not wear a protective gown while administering medications through the resident’s G tube. A sign for Enhanced Barrier Precautions was posted on the resident’s door. In interview, LVN B stated the resident did not have a specific order to wear a gown and that she only wore gloves during G-tube medication administration. The DON stated staff were expected to wear gowns and gloves any time they provided care indicating Enhanced Barrier Precautions, and the ADON stated staff should wear Enhanced Barrier Precautions during care involving a G tube. The facility policy on Enhanced Barrier Precautions identified device care or use, including feeding tubes, as a high-contact resident care activity requiring gown and glove use.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols while providing incontinent care to a resident with severe cognitive impairment and total dependence for activities of daily living. During care, one CNA touched the bed remote with gloved hands and another touched the privacy curtain with bare hands, but neither changed gloves or performed hand hygiene before starting direct care. Additionally, one CNA changed gloves multiple times during the care process but did not sanitize or wash hands between glove changes, contrary to facility policy and training. Both CNAs acknowledged during interviews that the bed remote and privacy curtain were considered dirty and admitted they did not realize the need to change gloves and sanitize hands before providing care. The Director of Nursing confirmed that staff are expected to change gloves and perform hand hygiene prior to care and between glove changes, as outlined in facility policy. Competency checks for both CNAs indicated prior demonstration of proper handwashing and incontinent care, and the facility's policy required hand hygiene before donning and after doffing gloves.
Failure to Address Resident's Left Hand Contracture
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with limited range of motion, specifically regarding a left hand contracture. The resident, a male with a history of Parkinson's disease and cerebral infarction, was observed without any preventative measures in place for his left hand contracture. Despite having a moderate cognitive impairment and requiring substantial assistance with eating, the resident's care plan and physician's orders did not address the contracture. Observations and interviews revealed that the resident's left hand was consistently in a fist position, and staff members, including a CNA and LVN, confirmed the absence of any assistive devices or preventative measures for the contracture. The resident expressed difficulty in opening his left hand and mentioned that it would develop an unpleasant odor, indicating a lack of proper hygiene and care for the contracted hand. The facility's documentation, including occupational therapy evaluations and care plans, failed to address the resident's left hand contracture. Interviews with the DON and DOR indicated that although the resident had been followed by various specialists, no specific recommendations were made for the contracture. The facility's policy on resident examination and assessment was not effectively implemented, as the contracture was not adequately assessed or managed.
Failure to Transmit Accurate MDS Data
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for four residents. Specifically, the facility did not correct and resubmit incorrect MDS assessments for three residents, and failed to transmit a completed MDS assessment for another resident. These deficiencies were identified during a review of the clinical records of the residents, which showed that the MDS assessments had either been returned with warnings or were still in process. The MDS Coordinator, responsible for completing and submitting these assessments, acknowledged during an interview that the errors were due to oversight. The facility's policy on the electronic transmission of MDS, revised in November 2019, mandates that all MDS assessments be completed, encoded, and transmitted in accordance with current OBRA regulations. However, the coordinator admitted that the assessments had not been corrected or transmitted as required, leading to the identified deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cotulla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearsall Nursing And Rehabilitation Center | 32.1 mi | ★★★★★ | 7 | 0 |
| Whispering Springs Rehabilitation And Healthcare C | 38.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Cotulla.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.