Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Irving during CMS and state inspections, most recent first.
Food Storage and Handling Deficiencies: Surveyors observed multiple food safety lapses in the kitchen, including an unsealed and unlabeled frozen dinner, unsealed and undated refrigerated items, dented cans in dry storage, an unsealed cereal bag, and a staff backpack stored under the food prep table. An employee also handled bread rolls with gloved hands instead of using tongs, contrary to the facility’s food handling policy.
Failure to Maintain Water Management Program: The facility failed to establish and maintain a water management program with a risk assessment for where Legionella and other opportunistic waterborne pathogens could grow and spread, and it did not document control measures or monitoring activities. The Maintenance Director could not identify current interventions or provide a risk assessment, the DON said she had no involvement in the water plan, and the ADM provided a binder with a policy and CDC guidance but no completed assessment or program measures.
Failure to obtain and document fluid restriction orders for a resident receiving dialysis. The resident had ESRD and was scheduled for dialysis three times weekly, but the chart contained no MD order for fluid restriction or fluid intake monitoring. Dialysis communication notes repeatedly instructed fluid restriction, including limiting fluids and reinforcing the restriction, yet nursing notes did not reflect those recommendations or communication to the MD/NP. Staff described relying on a dialysis binder and shift reports, while the NP and DON stated they were not aware of a fluid restriction order.
A resident with stroke-related diagnoses, impaired communication, and wheelchair dependence had a broken left wheelchair brake that he indicated had been broken for about a week. Staff interviews showed the therapy staff member was not aware of the issue until the morning it was observed, the DOR later reported the concern, and the Maintenance Director completed the repair after the resident was observed in the dining room. The facility stated staff could enter an electronic work order for damaged equipment, and the Maintenance Director monitored equipment monthly.
A resident with liver disease, depression, and PTSD, and with moderately impaired cognition, had physician orders for scheduled Hydrocodone-Acetaminophen TID for pain and Sertraline HS for depression, but multiple consecutive doses over several days were not administered as scheduled. MAR review showed repeated missed doses of both medications with blank documentation fields, while pain levels were consistently recorded as zero and nursing notes showed no pain indicators. The DON’s reconciliation of medication counts on the cart confirmed that the doses had not been given. Staff, including the DON and two MAs responsible for medication passes, reported they were unaware the medications had been missed and acknowledged that medications are expected to be given and documented per physician orders and facility policy.
The facility's kitchen failed to meet food safety standards, with issues including improperly labeled and stored food, inadequate dishwashing practices, and unsanitary conditions. Personal items and cleaning chemicals were stored improperly, and the ice machine was found dirty. The dietary manager cited staff shortages and oversight as contributing factors.
The facility did not maintain the required RN coverage for eight consecutive hours a day on 13 weekend days in April and May 2024. This was confirmed through staffing data and interviews with the DON and Administrator, who were new to the facility and unable to explain the absence of RN coverage prior to their arrival. The facility's policy mandates 24-hour licensed nursing and RN presence, which was not met.
A resident with multiple medical conditions alleged physical abuse by a Former Staffing Coordinator, who reportedly grabbed his hand hard enough to cause bruising while attempting to take him to the shower. The facility's investigation included interviews with staff and the resident, who described the incident as involving several female staff members. The resident expressed a preference for male staff during showers and felt safe overall, but the incident highlighted a failure in ensuring protection from abuse.
A resident with severe cognitive impairment and reliant on a G-tube for nutrition did not have their G-tube placement checked by RN H before administering water, medication, and feeding, contrary to physician orders and facility policy. This oversight occurred despite the resident's care plan and medical history indicating the necessity of such checks to prevent complications.
A facility failed to secure a Clonidine patch prescribed for a resident with high blood pressure, leaving it unattended on a medication cart. The CMA admitted the oversight, and the DON confirmed the expectation for medications to be secured to prevent unauthorized access.
A facility failed to maintain an effective infection prevention and control program when a nurse did not wear a gown while providing care to a resident on enhanced barrier precautions. The resident, with Alzheimer's and a g-tube, required these precautions to prevent MDRO transmission. The nurse misunderstood the need for gown use during g-tube care, contrary to the facility's policy and the resident's care plan.
A facility failed to implement its abuse prevention policy by not suspending the DON and an LVN after a resident alleged physical and emotional abuse. The resident, with multiple medical conditions, reported being coerced into a shower and handled roughly, resulting in a bruise. Discrepancies in staff and resident accounts complicated the investigation, and the facility's inaction was identified as a deficiency.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation on 02/24/2026 at 8:40 A.M., the stand-by freezer contained a large tub of ice cream with the lid not sealed and an unlabeled frozen dinner box. The stand-by refrigerator contained an unsealed bag of sliced cheese with no label or date, an unsealed bag of deli meat, and a used bag of shredded cheese with no label or date. In the dry storage closet, surveyors observed a dented can of chopped tomatoes, a dented can of banana pudding, and an unsealed bag of cereal. A backpack was also found under the food preparation table, and [NAME] E stated it was a personal item that she removed from under the counter because staff storage space was limited. During the same observation, [NAME] E stated that dented cans could allow air to get into the food and cause contamination, and that food needed to be sealed to keep contaminants out and remain fresh. On 02/25/2026 at 11:20 A.M., [NAME] E was observed using gloved hands to handle bread rolls on the steam tray line. At 11:30 A.M., the DM stated that tongs should have been used because of the risk of cross contamination. The DM also stated she had seen the frozen dinner in the freezer and threw it away, and indicated that dented cans and unsealed food items were a contamination risk. The facility's Food Storage policy required food to be stored in a clean, dry area free from contaminants, with foods covered, labeled, dated, and monitored, and the General Food Preparation and Handling policy stated that food should be prepared and served with clean utensils to avoid manual contact of prepared foods.
Failure to Maintain Water Management Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program related to water management. During interviews, the Maintenance Director stated that the document titled Water Management Program was the facility’s water management plan, but he was not aware of any water management binder and could not identify any interventions currently being used in a water management plan. He also could not provide any facility risk assessment related to the water management plan. The DON stated that she was the Infection Control Nurse for the facility and had no information or involvement in any facility water plan, and said the plan was handled by the ADM. During interview and record review, the ADM provided a binder as evidence of a water management program that included a policy titled Water Management Program with the date implemented written as 2/25/26. The binder also contained a CDC document titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings and a facility water flow diagram. However, there was no diagram or other indication that the facility had completed a risk assessment of where Legionella and other waterborne pathogens could grow and spread, and the binder did not include measures to be implemented as part of the program. The ADM was unable to provide the assessment, identified measures, or documentation of water management activities, and stated, “We don't need a plan. We don't have Legionella.” The ADM also stated there were no rooms closed or unused at the facility and no residents had experienced Legionella infection in the past year.
Failure to Obtain and Document Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end stage renal disease who received dialysis three times per week. The resident’s record showed orders for dialysis on Monday, Wednesday, and Friday, but no physician order for fluid restriction or fluid intake monitoring was present. The care plan, however, included interventions to monitor compliance with fluid restriction per MD order and to monitor the resident’s condition before and after dialysis. The dialysis communication notes from the dialysis center repeatedly documented fluid restriction recommendations. Thirteen of 36 notes under the section for facility completion included directions such as controlling fluid intake, limiting fluids, fluid intake restriction of 32 ounces per day, and fluid restriction reinforced. The resident also returned for extra dialysis treatments on Tuesday, and one progress note stated the dialysis center called to report the resident had a lot of fluids and needed to return the next day. The progress notes did not reflect the dialysis communication form notes for fluid restrictions or any notification to the MD or NP about those recommendations. During interviews, nursing staff described using the dialysis binder and shift reports to communicate dialysis information, but they also acknowledged that fluid restriction information was not consistently entered into the electronic record and that no order for fluid restriction was present. The NP stated she was not aware of the dialysis recommendation for fluid restriction and said nurses had not communicated it to her. The DON stated the resident was not on a fluid restriction and confirmed there was no MD order for it, while also acknowledging that the resident had gone to dialysis on an extra day due to fluid overload. The facility’s dialysis care coordination agreement stated that the facility would furnish information and documentation necessary for the dialysis facility to provide safe and appropriate care.
Broken Wheelchair Brake Not Maintained
Penalty
Summary
The facility failed to maintain a working brake on the left wheel of one resident’s wheelchair. Resident #1 was a male admitted with diagnoses including cerebral infarction, difficulty walking, unsteadiness on feet, other lack of coordination, and cognitive communication deficit. His quarterly MDS reflected functional limitations in range of motion of the lower extremities, normal use of a wheelchair, and that his BIMS was not assessed because he was never or rarely understood. During observation and interview, the resident used gestures to indicate that the left wheelchair brake was broken, while the right brake was working and the left brake did not stop the wheel from moving. He stated the brake had been broken for about one week and that he had told staff in the nursing department. Staff interviews showed that the therapy staff member who completed the resident’s therapy evaluation was not aware of the broken brake until the morning of the observation and informed the DOR. The DOR stated the resident had tremors and pushed down too hard on the wheelchair brakes, and that this was the second time in the past one to two weeks that the brake had been replaced. The DON stated the resident had gestured that the brake was broken and she notified the DOR. The Maintenance Director later completed the repair while the resident was sitting in the dining room, and the electronic maintenance record showed the work order was created after the issue was reported. The facility’s maintenance process was described as staff notifying supervisors or entering an electronic work order, and the Maintenance Director stated he monitored equipment monthly.
Failure to Administer Ordered Pain and Antidepressant Medications as Scheduled
Penalty
Summary
Surveyors identified a failure by the facility to provide pharmaceutical services that ensured accurate dispensing and administration of medications as ordered for one resident. The resident was an adult female with cirrhosis of the liver, metabolic encephalopathy, chronic hepatitis, depression, and PTSD, with a BIMs score of 8 indicating moderately impaired cognition. Her admission MDS documented use of antidepressant and scheduled pain medications, and her care plan included problems related to liver disease and antidepressant use, with interventions to administer medications as ordered and monitor effectiveness and side effects. Review of the resident’s January 2026 physician orders showed an order for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth three times daily for pain starting 01/10/26, and Sertraline 50 mg by mouth at bedtime starting 01/09/26. The DON stated that TID medications were scheduled for 8 AM, 2 PM, and 8 PM, and HS medications at 8 PM. The January 2026 MARs, documented by two medication aides, showed that the resident missed multiple scheduled doses of Hydrocodone-Acetaminophen on 01/12/26 (2 PM, 8 PM), 01/13/26 (8 AM, 2 PM, 8 PM), 01/14/26 (8 AM, 2 PM, 8 PM), and 01/15/26 (8 AM, 2 PM, 8 PM). The MAR also showed missed Sertraline doses on 01/12/26, 01/13/26, 01/14/26, and 01/15/26 at 8 PM. Despite these missed doses, the MAR documented a pain level of zero from 01/10/26 to 01/16/26, and nursing progress notes from 01/11/26 to 01/16/26 contained no indicators of pain or discomfort. A pain interview on 01/12/26 recorded that the resident experienced pain rarely or not at all. On 01/16/26, the DON reconciled the Hydrocodone-Acetaminophen and Sertraline tablets on the medication cart with the MAR and confirmed that the resident had not received the medications as ordered. Interviews with the resident, the DON, the administrator, both medication aides, and the Activity Director showed that facility staff were unaware that the medications had not been administered, and staff acknowledged that blank MAR entries indicated medications were not given. Facility policies on documentation of medication administration and physician orders required that all medications administered be documented and that physician orders be followed to ensure residents receive necessary care and services.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Food items in dry storage, as well as frozen and refrigerated items, were not properly dated, labeled, or securely stored. This included open bags of bread, undated and unlabeled containers of cottage cheese, cocktail sauce, and various frozen foods. Additionally, a metal container of butter was left uncovered with a pastry brush inside, posing a risk of contamination. The steam table was found with uncovered breakfast items and an accumulation of debris, indicating a lack of proper maintenance and cleanliness. The dishwashing protocol was not followed correctly, with the low-temperature dishwashing machine operating at an insufficient temperature of 103 degrees Fahrenheit, and the temperature gauge appeared broken. The 3-compartment sink was not used properly, as the sanitizer solution was not adequately prepared, and dishes were not sanitized correctly. Clean dishware was stored uncovered, exposing it to potential contamination. Furthermore, the ice machine was found to be dirty, with mold-like substances inside, and there was confusion among staff regarding who was responsible for its cleaning. Personal items were improperly stored in the dry storage closet, and cleaning chemicals like bleach were stored next to food items, increasing the risk of contamination. The facility's dietary manager acknowledged these issues, citing a lack of staff and oversight as contributing factors. Despite previous audits and recommendations from the dietitian, these deficiencies persisted, indicating a failure to implement necessary corrective actions and maintain a safe and sanitary kitchen environment.
Failure to Maintain Required RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for a minimum of eight consecutive hours a day, seven days a week, on 13 out of 26 weekend days in April and May 2024. This deficiency was identified through a review of the CMS PBJ Staffing Data Report and an undated excel file, which both indicated a lack of RN coverage on specific weekend dates. The absence of RN coverage was confirmed during interviews with the Director of Nursing (DON) and the Administrator, both of whom were relatively new to the facility and unable to account for the missing RN hours prior to their tenure. The DON, who began working at the facility in August 2024, acknowledged the importance of RN coverage, noting that an RN's higher level of knowledge and training is crucial for addressing certain resident needs. Despite covering for the weekend RN on two occasions, the DON was unaware of the reasons for the lack of coverage before her arrival. The facility's policy on Nurse Staffing Requirements mandates 24-hour licensed nursing and the presence of an RN for eight consecutive hours daily, which was not adhered to, as evidenced by the missing RN hours on the specified dates.
Resident Abuse Incident Involving Former Staffing Coordinator
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse, as evidenced by an incident involving the Former Staffing Coordinator and a resident. The resident, a male with multiple medical conditions including acute embolism, thrombosis, and cauda equina syndrome, alleged that the Former Staffing Coordinator grabbed his hand hard enough to cause bruising while attempting to take him to the shower. The resident expressed that he preferred to have his showers when a friend was present to watch over his belongings, as he was concerned about his items being discarded by staff during his absence. The incident was self-reported by the facility to the Health and Human Services Commission (HHSC) after the resident made the allegation. The facility's investigation included interviews with staff and the resident, who described the incident as involving several female staff members, including the Former Staffing Coordinator, who allegedly handled him roughly. The resident reported feeling safe overall and did not express fear of other staff members, but he was clear about the physical discomfort and the bruise on his hand resulting from the incident. Interviews with staff members provided varying accounts of the incident. CNA I recalled the Former Staffing Coordinator holding the resident down, while the Former Staffing Coordinator denied any rough handling. The facility's Former Administrator and other staff members conducted an investigation, but the Former Staffing Coordinator left the facility and did not provide a statement. The facility's abuse prevention policy emphasizes the importance of preventing abuse and educating residents, families, and staff on reporting concerns, but the incident highlighted a failure in ensuring the resident's protection from abuse.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident who required medication administration via a gastrostomy tube (G-tube). The deficiency was identified when RN H did not check the placement of the resident's G-tube before administering water, medication, and feeding. This oversight occurred despite the physician's orders and facility policy requiring the verification of G-tube placement prior to any administration to prevent potential complications. The resident involved was an elderly female with severe cognitive impairment, dependent on staff for all activities of daily living, and reliant on a G-tube for more than half of her nutritional intake. Her medical history included Alzheimer's disease, muscle weakness, and adult failure to thrive. The resident's care plan and physician orders explicitly stated the need to check G-tube placement and residuals before feeding and medication administration, which RN H failed to do during the observed incident. During interviews, RN H admitted to forgetting to re-check the G-tube placement due to nervousness from being observed. The Director of Nursing (DON) confirmed that the nurse should have followed the physician's orders and checked the G-tube placement to avoid risks such as tube migration or incorrect administration. The facility's policy on administering medication through an enteral tube also emphasized the importance of confirming tube placement before proceeding with any administration.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, a Clonidine patch, prescribed to a resident for high blood pressure, was left unattended on top of a medication cart by a Certified Medication Aide (CMA). The medication cart was out of view due to a privacy curtain, and a staff member was observed passing by the unattended cart. This oversight could have led to unauthorized access to the medication. The resident involved was a male with a history of unspecified dementia, high blood pressure, and stroke. His care plan included the administration of a Clonidine patch weekly to manage malignant hypertension. The CMA acknowledged the mistake, stating that the medication should have been locked in the cart or taken into the resident's room. The Director of Nursing (DON) confirmed the expectation for medications to be secured and acknowledged the risk of leaving them unattended.
Failure to Follow Enhanced Barrier Precautions for Resident with G-Tube
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN H, who did not wear a gown while providing care to a resident on enhanced barrier precautions. This resident, a female with Alzheimer's disease, muscle weakness, lack of coordination, adult failure to thrive, and gastrostomy status, required enhanced barrier precautions due to a feeding tube and a wound on the lower extremity. The resident's care plan specified the need for gowns and gloves during high-contact care activities, including g-tube care, to prevent the transmission of multidrug-resistant organisms (MDROs). During an observation, RN H was seen providing g-tube care without wearing a gown, contrary to the facility's policy and the resident's care plan. RN H admitted to not wearing a gown for g-tube care, indicating a misunderstanding of the precautions required for indwelling medical devices. The Director of Nursing (DON), who also serves as the infection control preventionist, confirmed that all nursing staff are expected to follow enhanced barrier precautions, including wearing gowns for g-tube care. The facility's policy on standard and transmission-based precautions also supports the need for gown and glove use during high-contact activities for residents with indwelling medical devices.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its own written abuse and neglect prevention policy and procedure for a resident who was reviewed for abuse and neglect. The deficiency involved the failure to immediately suspend two staff members, the DON and an LVN, pending investigation when an allegation of physical and emotional abuse was made. The incident involved a resident who alleged that female staff members entered his room, attempted to force him to take a shower against his will, and handled him roughly, resulting in a bruise on his hand. Despite the facility's policy requiring the immediate removal of alleged perpetrators from contact with residents, the DON and LVN were not suspended immediately when corporate staff became aware of the situation. The resident involved was an elderly male with multiple medical conditions, including acute embolism, urinary tract infection, lack of coordination, spondylolisthesis, and cauda equina syndrome. He was admitted to the facility with a BIMS score indicating possible moderate cognitive impairment but was able to express himself and understand others. The resident reported that during the incident, he was handled roughly by a staff member who grabbed his hand, leaving a bruise. He also mentioned that he preferred to be showered by male staff and was concerned about his personal belongings being removed from his room when he was not present. Interviews with staff and the resident revealed discrepancies in the accounts of the incident. A CNA who witnessed the event reported that the DON and LVN were involved in coercing the resident to shower and that water was poured on him while he was in bed. However, the resident later denied that water was poured on him and stated that the main issue was the rough handling by a staff member. The facility's investigation was complicated by the departure of the Former Staffing Coordinator, who was initially suspended but did not return to provide a statement. The facility's failure to follow its abuse prevention policy and the lack of immediate suspension of the involved staff members were identified as deficiencies in protecting residents from potential abuse.
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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.
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Nursing homes near Irving
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Ashford Hall | 1.1 mi | ★★★★★ | 14 | 0 |
| The Villages On Macarthur | 2.5 mi | ★★★★★ | 1 | 0 |
| Northgate Plaza | 3.1 mi | ★★★★★ | 16 | 0 |
| Las Brisas Rehabilitation And Wellness Center | 4.6 mi | ★★★★★ | 4 | 0 |
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