Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Kennedale during CMS and state inspections, most recent first.
A facility failed to report an injury of unknown source after a resident with severe cognitive impairment and a history of shoulder problems developed a swollen, discolored, dislocated shoulder. Staff noted pain, redness, and swelling, obtained an x-ray, and later sent the resident to the ER. The Administrator said the injury was not reported because it was believed to be chronic and no investigation was done because it was not considered new.
The facility did not maintain required RN coverage for at least eight consecutive hours daily, as shown by staffing records indicating multiple weekend days without any RN on duty during a two‑month review period. The facility’s own staffing policy required an RN to provide services eight hours every 24 hours, seven days a week, but this was not met. In interviews, the ADON, DON, and Administrator acknowledged ongoing difficulty hiring and retaining a weekend RN, confirmed that the facility had been without weekend RN coverage for an extended period, and recognized that an RN is needed for tasks outside LVN scope and for appropriate oversight.
A resident with multiple chronic conditions and dysphagia received ordered bolus g-tube feedings of Glucerna 1.5, but an LVN prepared a feeding by adding an unknown amount of tap water to the formula before administration, contrary to the physician’s written orders and facility policy. The LVN reported diluting the formula so it would flow more quickly and believed this was permitted, while the ADON and DON both stated that g-tube formula should not be diluted without a specific physician order and that enteral nutrition is to be provided exactly as ordered.
A resident with multiple chronic conditions and a g-tube for dysphagia received several ordered oral medications (including apixaban, atorvastatin, acetaminophen-codeine, and calcium carbonate-vitamin D) via g-tube in a manner that did not follow facility policy. An LVN routinely crushed and mixed all of the resident’s medications together in one cup, added a large volume of water, and administered the combined mixture through the g-tube, rather than preparing and giving each medication separately with appropriate water flushes between them. The ADON and DON reported they were unaware this practice was occurring and confirmed that it was inconsistent with the facility’s written enteral medication administration policy, which requires separate preparation and administration of each medication unless there is a specific physician order to mix them.
A resident with hemiplegia, non-Alzheimer’s dementia, aphasia, moderate cognitive impairment, and total dependence for care was observed receiving incontinence care and a shower from a CNA who failed to follow infection control practices. The CNA continued perineal care, applied a clean brief, handled a Hoyer sling and lift, transferred the resident, and provided a shower while wearing gloves visibly soiled with fecal matter, without performing hand hygiene or changing gloves. The CNA only removed gloves after the shower and then dried the resident without hand hygiene. Staff interviews and facility policies confirmed that hand hygiene and glove changes were required when gloves are soiled, when moving from dirty to clean tasks, and when entering or exiting rooms, and that not doing so could cause infection, cross-contamination, spread of germs, or fungal issues.
A resident with a history of stroke, pressure ulcers, and mobility-related skin concerns had a physician order for Mupirocin 2% ointment to be applied to the left great toe twice daily after cleansing and covering with a dry dressing, but the Treatment Administration Record showed missing documentation of twice-daily wound care on multiple days, and observations found the toe dressing unchanged over several hours. The treatment nurse and an LVN both believed or acted as though the wound care was ordered once daily, and the LVN acknowledged not providing the wound care that day, while the regional nurse consultant stated staff follow physician orders and noted the risk of not following them. The facility’s wound care policy required verification of physician orders and documentation of the date and initials of the person performing wound care.
A resident with multiple wounds and moderate cognitive impairment did not receive or have documented wound care on several occasions as ordered by the physician. Nursing staff failed to document the provision of wound care or any refusals, and facility leadership was unaware of the missed care. This resulted in a failure to ensure necessary treatment and services were provided according to professional standards.
Failure to Care Plan Known Elopement Risk: A resident with Alzheimer’s disease, moderate cognitive impairment, and a history of exit-seeking was identified as high risk for elopement, but the care plan did not address those behaviors. The resident later eloped from the facility and was found outside near an apartment complex by a passerby, then returned after staff were notified. Staff interviews confirmed the resident had repeatedly tried to leave, asked for the door code, and followed others toward exits.
Elopement Supervision Failure: A resident with Alzheimer’s disease, moderate cognitive impairment, and a known history of exit-seeking left the facility and was found near an apartment complex on a busy street by a passerby who returned her. Staff could not explain exactly how she exited, and the resident told staff she was going to get her car. Her care plan had not addressed her exit-seeking behaviors before the event, and the record identified her as high risk for elopement.
Resident Council Meetings Held Without Privacy: The facility failed to provide a private meeting space for resident council meetings for 8 of 8 confidential residents reviewed. A resident council meeting was held in an open dining room near the nurses' station and front entry door, with portable privacy screens and a sign posted, but no doors or audial privacy. Residents reported meetings were routinely held in this area because there were no private spaces large enough for residents, including those using wheelchairs, and the Activity Director and Administrator stated they were unsure of a better location.
The facility failed to follow physician-ordered weight monitoring for two residents. One resident with malnutrition, a feeding tube, and hospice care was supposed to be weighed weekly but was later weighed only twice a month and then monthly despite ongoing weight loss. Another resident with morbid obesity and DM2 was ordered weighed every 3 days but was later weighed only monthly, with a documented 20-pound gain and no weight recorded for one month. Staff interviews showed the ordered monitoring was not being tracked consistently.
The facility failed to have RN coverage for at least 8 consecutive hours on multiple weekend days. Timecard review showed no RN coverage on several dates, and the DON stated she was not aware the schedules lacked an RN because ADON C completed the schedules and she reviewed them after the fact. The Administrator also confirmed she was unaware of the missing RN coverage and stated the facility did not have a policy for RN coverage, instead following CMS guidelines.
Pureed Menu Preparation Did Not Follow Recipe Directions: A cook prepared pureed chicken and rice for lunch by adding water twice to each item instead of using the recipe-approved liquids. The items were blended to a mashed potato consistency, but the chicken did not appear fully blended. The cook acknowledged knowing the recipe said not to add water, and the DON stated staff were expected to follow the recipes and use the correct consistency.
Pureed Chicken Served at Incorrect Consistency: A pureed lunch item was prepared and served without being blended to the required pudding-smooth consistency. A cook added water without measuring, added thickener, and blended the chicken briefly before portioning it, but neither the cook nor the Dietary Manager verified the texture. The test tray showed the pureed chicken was not smooth and contained bristle, and the Dietary Manager stated it was not the correct consistency.
Failure to include a resident and POA in quarterly care plan meetings. A resident with dementia, cognitive communication deficit, depression, HTN, and severe cognitive impairment had no documented care conference since the prior year, and the chart lacked evidence that the resident or POA were invited or informed of quarterly meetings. The POA stated he had concerns about care but was never invited to address them, while the DON and Administrator said the SW and ADON C/MDS Coordinator were responsible for scheduling the meetings.
A resident with Alzheimer’s disease, cognitive impairment, and a known history of exit-seeking eloped from the facility and was found near an apartment complex by a passerby who returned her. Staff documented the resident was gone only a few minutes and had no injuries, but the DON and Administrator did not report the incident to HHSC because they believed it was not reportable. The resident’s care plan did not address her exit-seeking behavior until after the event.
Failure to Report Resident Elopement as a Reportable Neglect Event: A resident with Alzheimer’s disease, moderate cognitive impairment, and a known history of exit-seeking behavior eloped from the facility and was found near an apartment complex by a passerby who returned her. Staff documented the event as lasting only a few minutes with no injury, and the DON and Administrator decided it was not reportable, so HHSC was not notified despite the facility policy requiring reporting of neglect allegations and related events.
A resident with HTN, dementia, cognitive communication deficit, depression, and severe cognitive impairment had a quarterly MDS completed, but the comprehensive care plan was not reviewed and revised by the IDT afterward. The last care conference was documented as an annual meeting, and there was no charted evidence that the family/POA was notified or invited to quarterly care plan meetings; the POA stated he had concerns and had not been included in recent meetings.
A resident with dysphagia, GERD, and intact cognition was observed in bed with sucralfate left on the bedside table, with part of the tablet in her mouth and the rest in a medication cup. The assigned RN stated she had left the medication in the room because the resident took time to take her meds, and the DON stated nurses were expected to stay in the room and observe medication administration rather than leave meds unattended.
Failure to Notify POA Before Transfer: A resident with Alzheimer’s disease and moderate cognitive impairment was transferred to another facility after an elopement event, but the record showed no documented notice to or involvement of the POA/family before discharge. The LVN said she did not contact the family, the DON assumed someone else had, and the family stated they only learned of the transfer after it occurred. The MD expected the family to be notified before the move, and the facility policy required notification prior to transfer or discharge.
A resident with Alzheimer’s disease, anxiety, depression, DM, muscle wasting, and unsteadiness was discharged to another NH, but the clinical record had no discharge summary. The chart only showed a discharge progress note documenting baseline VS, BM, med reconciliation, belongings gathered, and report given; interviews showed confusion over responsibility, and the Administrator and DON acknowledged the discharge summary was not completed.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on nine occasions. This was due to RNs, including the DON, working shifts that did not meet the required duration, often because of breaks. The DON was unaware of the non-compliance, and the facility lacked a specific policy for RN coverage, relying instead on CMS guidelines.
A resident receiving IV Meropenem for sepsis and bacteremia was administered medication by an LVN who failed to label the IV bag and tubing with the date, time, and her initials, as required by facility policy. The LVN acknowledged the oversight, which could lead to medication errors and infection control issues. The DON confirmed the labeling requirement, but no adverse events had occurred yet.
The facility failed to accurately report licensed nurse hours to CMS for eight days in FY Quarter 1 2024, despite having 24-hour coverage according to staff timesheets. The issue was due to a system error in pulling LVN worked hours, which the Corporate Analyst identified and corrected. The Administrator was unaware of the reporting details, and the facility lacked a specific PBJ staffing policy.
Failure to Report Resident Shoulder Injury
Penalty
Summary
The facility failed to report an injury of unknown source to HHSC after a resident sustained a dislocated left shoulder. The resident was a female with diagnoses including emphysema, dementia, and cognitive impairment, with a BIMS score of 1 indicating severe cognitive impairment. Her care plan noted limited physical mobility, high fall risk, use of a manual wheelchair, dependence on staff for ADLs, and a history of prior collar bone and shoulder dislocation with loose hardware in the shoulder. On 04/18/26, the resident complained of left shoulder pain and the physician was notified; a STAT x-ray was ordered and pain medication was given. The next day, staff noted redness and swelling to the left shoulder with grimacing on touch, and the x-ray result was printed and the physician notified. The resident was then sent to the ER for further evaluation. The EMS report stated staff had sent a picture of the injury and were advised not to call 911 because the facility would do its own imaging, and that the injury was over 24 hours old at that point. Hospital records confirmed the left shoulder was dislocated. During interviews, staff stated the resident had not fallen that they knew of and was normally transferred with two people using a gait belt. One CNA said she noticed the shoulder looked discolored while getting the resident ready for bed and showed the photo to an LVN. The Administrator stated the injury was not reported because the resident had a chronically dislocated shoulder and the physician did not think it was acute, and there was no investigation because it was not new. The Physician later stated that although he initially believed the dislocation was not new, the resident would not have been able to use her left arm to propel her wheelchair if the shoulder had remained dislocated since 2023, and he believed the dislocation was most likely acute.
Failure to Maintain Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulation and by its own policy. Review of the facility’s Detailed Hours report for the period from 02/07/26 to 04/05/26 showed there was no RN coverage on multiple weekend dates: 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, and 03/29/26. The facility’s written policy on Staffing, Sufficient, and Competent Nursing, revised August 2022, stated that an RN would provide services at least eight hours every 24 hours, seven days a week, but this was not followed on the identified dates. During interviews, the ADON stated the facility had been having difficulty finding and retaining an RN for weekend coverage and acknowledged they had been without one for “quite a while.” The ADON also stated an RN should be present on weekends in case something occurred that was outside the scope of practice of an LVN. The newly hired DON, who had been at the facility for three days, reported being told that the facility had recently lost its weekend RN and was not aware there were so many days without RN coverage, and affirmed that having an RN for eight consecutive hours Monday through Sunday was important because it was a state regulation. The Administrator similarly reported that the facility had not had a weekend RN for quite some time and acknowledged the importance of having an RN seven days a week for eight hours for tasks outside LVN scope and for better oversight.
Unauthorized Dilution of Enteral Formula Prior to G-Tube Administration
Penalty
Summary
The deficiency involved a failure to ensure that a resident receiving enteral nutrition via a g-tube received treatment and services in accordance with physician orders and facility policy. The resident was an older female with multiple diagnoses including hypertension, hyperlipidemia, respiratory failure, diabetes, end stage renal disease, and pain, with moderately impaired cognition and a care plan indicating the need for tube feeding related to dysphagia. Her physician orders specified bolus enteral feedings of Glucerna 1.5, with defined volumes and times. During an observation, LVN C prepared the resident’s g-tube feeding by pouring an undisclosed amount of tap water into cups containing the ordered formula before administering it through the g-tube, then flushing with water afterward. In a subsequent interview, LVN C stated she added water to the formula to dilute it so it would not take a long time to go down the tube and acknowledged she did not recall how much water she used. She reported believing she had been told by the ADON that she could dilute the formula, but the ADON later stated she was not aware LVN C was diluting the formula and denied instructing her to do so, clarifying that dilution could only occur with a physician’s order. The DON also stated the resident’s formula should not have been diluted without a physician’s order and that doing so could affect the concentration of the formula or cause overload and put the resident at risk of aspiration. The facility’s Enteral Nutrition policy indicated that enteral nutrition would be provided as ordered by the physician based on dietitian recommendations, which was not followed in this instance.
Improper Mixing and Administration of G-Tube Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications via a g-tube in accordance with facility policy for one resident. The resident was an adult female with multiple diagnoses including hypertension, hyperlipidemia, respiratory failure, diabetes, end stage renal disease, and pain, and had a g-tube for tube feeding related to dysphagia. Her physician’s orders included several oral tablets (apixaban, atorvastatin, acetaminophen-codeine, and calcium carbonate-vitamin D with minerals) to be administered via g-tube. During an observation, LVN C was seen crushing four pills together in a single pouch, pouring the combined crushed medications into one cup, then adding approximately 110 mL of water before administering the mixture through the resident’s g-tube. She flushed the g-tube before and after giving the combined medications and then administered the feeding formula, and the resident did not show signs of discomfort or distress during the procedure. In interviews, LVN C stated she always combined and crushed this resident’s medications, explaining that she had heard other nurses administered crushed medications one by one but felt that doing so would take too long, and that no one had told her not to mix them together. She also acknowledged she did not realize she had used so much water and usually used about 30 cc, and that cocktailing medications could possibly affect their effectiveness. The ADON and DON both reported they were not aware that LVN C was mixing the resident’s medications and stated that g-tube medications should be crushed, placed in separate cups, and administered one at a time with water flushes between each medication, and that mixing medications should only occur with a physician’s order. Review of the facility’s “Administering Medications through an Enteral Tube” policy confirmed that medications were not to be mixed together prior to administration through an enteral tube, that each medication should be administered separately unless there was a physician’s order to mix them, that crushed medications should be diluted with 15–30 mL of water, and that 15 mL water flushes should be used between medications when more than one medication is administered.
Failure to Perform Hand Hygiene and Change Soiled Gloves During Incontinence Care and Shower
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care and showering. A female resident with hemiplegia following cerebral infarction, non-Alzheimer’s dementia, aphasia, moderate cognitive impairment (BIMS score of 8), and total dependence for care was observed receiving incontinence care and a shower. She was incontinent of bowel and bladder and required staff assistance for all care, including perineal care with mild cleansers and repositioning. During an observation, CNA A and CNA B prepared to provide incontinence care and a shower. CNA A donned clean gloves and began perineal care after opening the resident’s brief. On the last wipe, brown fecal matter was observed on CNA A’s gloves. After the resident was turned onto her side, CNA A reached over the resident, leaving brown fecal residue on the resident’s left leg and the bed pad. CNA A then used new wipes to clean the resident’s buttocks, during which the resident had a soft bowel movement. After cleaning, CNA A rolled the soiled brief and discarded it, but brown fecal matter remained on her gloves. Without performing hand hygiene or changing gloves, CNA A obtained a clean brief, placed it under the resident’s buttocks, retrieved and placed the Hoyer sling under the clean brief, and assisted in securing the clean brief. Still wearing the same soiled gloves, CNA A retrieved the Hoyer lift, assisted with transferring the resident into the shower chair, and pushed the resident through the hallway into the shower room. CNA A then provided the resident’s shower while wearing the same contaminated gloves used during incontinence care. Once the shower was completed, CNA A removed her gloves and began drying the resident without having performed hand hygiene before or after incontinence care or the shower, and without changing gloves when they became visibly soiled. Interviews with CNA B, CNA A, the ADON, DON, and the Administrator confirmed that facility expectations and written policies required glove changes and hand hygiene when gloves are soiled, when moving from dirty to clean tasks, and when entering and exiting resident rooms, and that failure to do so could cause infection, cross-contamination, spread of germs, or fungal issues.
Failure to Follow Physician Orders for Toe Wound Care
Penalty
Summary
The facility failed to provide proper foot care and follow physician orders for wound care for one resident with a left great toe wound. The resident was an older female with a history of stroke affecting the left side, pressure ulcers, morbid obesity, skin concerns related to mobility issues, and an ADL self-care deficit. A physician’s order dated 02/09/26 directed that Mupirocin 2% ointment be applied to the left great toe twice daily after cleansing with antimicrobial solution and then covering with a dry dressing or bandage. The February 2026 Treatment Administration Record showed no documentation that this wound care was provided twice daily on multiple dates, specifically the 11th, 12th, 13th, 14th, 16th, and 18th. On 02/19/26, surveyors observed that the resident’s left great toe dressing was dated 2/18 and remained unchanged through several observations that day. The treatment nurse stated she handled major wounds while bedside nurses handled minor wounds and believed this resident’s wound care was ordered once daily; she could not explain why the wound care had not been done on 02/19/26. Upon removing the dressing, the treatment nurse observed the toenail was missing with a pink, healthy nailbed and no signs of infection. An LVN working the 6:00 AM–2:00 PM shift stated she normally did wound care at the end of her shift, had not provided this resident’s wound care that day, and was unaware the order was for twice-daily treatment. The regional nurse consultant stated staff followed physician orders for wound care and that the risk of not following the physician’s order was that the physician would be upset. The facility’s wound care policy required verification of the physician’s order and documentation of the date and initials of the person performing wound care.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with pressure ulcers did not receive necessary wound care treatment and services as ordered by the physician on four specific dates. Documentation review revealed that there was no record of wound care being provided on those dates, and the assigned nurse did not document the care or any refusal by the resident. The resident's care plan included interventions for pressure ulcer prevention and treatment, and physician orders specified daily wound care regimens for multiple wound sites. Interviews with facility staff, including the ADON and DON, confirmed that it was the responsibility of the nursing staff to provide and document wound care according to physician orders. Both the ADON and DON were unaware that wound care had not been documented or potentially not provided on the identified dates. The ADON stated that she was not informed of any refusals by the resident, and the DON indicated that wound care might have been provided but not documented. The facility's wound care policy required documentation of wound care, including the date, initials of the person performing care, and any resident refusals or changes in condition. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and type 1 diabetes mellitus, and was assessed as having moderate cognitive impairment. The resident had an unstageable pressure injury, a surgical wound, and a skin tear upon admission. The lack of documentation and uncertainty about whether wound care was provided on the specified dates constituted a failure to ensure the resident received necessary treatment and services consistent with professional standards of practice.
Failure to Care Plan Known Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Alzheimer’s disease, anxiety, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and unspecified lack of coordination. The resident had moderate cognitive impairment with a BIMS score of 11 and was identified as high risk for elopement, with a history of exit-seeking behaviors and attempts to leave the facility. The resident’s care plan dated 06/19/25 did not address these exit-seeking behaviors. An elopement/wandering observation quarterly assessment dated 06/18/25 identified the resident as high risk for elopement, noting a medical diagnosis associated with confusion and that the resident was physically able to exit on foot or by wheelchair. A later elopement risk evaluation dated 08/08/25 also identified the resident as at risk for elopement and noted a history of attempting to leave the facility one or more times in the last week, along with statements and/or threats to leave the facility. Despite these findings, the resident’s care plan had not been developed to reflect the identified behaviors before the event. On 08/08/25, the resident eloped from the facility and was found near an apartment complex on a busy street next to the facility by a passerby who brought her back. Progress notes documented that the resident reported she was going back home and was successfully redirected after return. Staff interviews stated the resident had a history of saying she wanted the code for the door, stating she was going with others leaving the building, pushing on doors, and being easily redirected. The DON and Administrator stated they were not aware the resident’s exit-seeking behaviors had not been care planned before the elopement.
Elopement Supervision Failure
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to provide adequate supervision to prevent accidents for a resident who was at high risk for elopement. The resident had diagnoses including Alzheimer’s disease, anxiety disorder, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and lack of coordination. Her MDS reflected moderate cognitive impairment with a BIMS score of 11, and the record identified her as physically able to exit on foot or by wheelchair. The resident had a history of exit-seeking behavior, including statements about wanting the code for the door, saying she was going with others who were leaving, and attempting to push doors so alarms would sound. Her care plan dated before the event did not address exit-seeking behaviors. The elopement risk evaluation completed after the event identified her as high risk and noted a history of attempting to leave the facility and statements or threats to leave. The facility’s records also reflected that she was known to propel her wheelchair quickly. On the morning of the event, the resident left the facility and was found near an apartment complex on a busy street next to the facility by a passerby, who brought her back and asked if she lived there. Staff reported that the resident had been outside for only a few minutes and that no alarm was heard. Staff interviews indicated the resident was last seen in the dining area or after breakfast, and they could not explain exactly how she exited. The resident told staff she was going to get her car. The facility’s elopement policy required staff to search the home and grounds, send staff to locate the resident, notify administration immediately, and call police if the resident was not found within 30 minutes.
Resident Council Meetings Held Without Private Space
Penalty
Summary
The facility failed to provide a private meeting space for resident council meetings for 8 of 8 confidential residents reviewed. During a confidential resident group interview with eight residents, the monthly resident council meeting was held in an open dining room near the central nurses' station and front entry door, with no doors that could be closed to ensure privacy. The Activity Director placed portable privacy screens in the dining room and a sign outside stating, "STOP Resident Council in Progress," but the screens only provided visual privacy and did not provide audial privacy. Staff were observed walking through the area during the meeting, and staff were standing by the central nurses' station while the meeting was in progress. The eight residents in attendance reported that their resident council meetings had been held in this open dining room area and that they had tried other areas of the facility, but there were no private areas that would hold residents, especially those using wheelchairs. The Activity Director stated she had only been at the facility for about a week and was not sure where to hold the meeting, and she said neither the Administrator nor the DON provided recommendations. The Administrator stated resident council meetings had been held in the dining area, sometimes blocked off with signs and privacy screen dividers, and that the facility was exploring options for a better place. The facility's Resident Council policy stated the facility is responsible for providing an adequate space that residents may gather in confidence.
Failure to Follow Ordered Weight Monitoring for Two Residents
Penalty
Summary
The facility failed to ensure two residents were weighed according to physician orders and facility policy. One resident had malnutrition, required substantial assistance with eating, received nutrition via feeding tube, and was on hospice care. The physician ordered weekly weights because the resident weighed less than 100 pounds and had a feeding tube, but after a period of weekly weighing the resident was only weighed twice a month and then monthly instead of weekly. The record showed progressive weight loss over time, and staff interviews reflected that multiple staff members were unaware of the weekly weight order or the resident's weight loss. The resident's care plan reflected poor nutritional intake, therapeutic diet, monthly weights, and reporting to the physician for 5% weight changes. Dietitian notes showed repeated monthly review and adjustments to tube feeding and supplements in response to weight loss. Hospice records documented the resident's declining condition, pain, anxiety, and a chest mass assumed to be cancer. Interviews with the resident, physician, DON, CNA, dietitian, and dietary manager confirmed the resident was losing weight, had poor appetite, and was receiving tube feedings and supplements, but the ordered weekly weight monitoring was not followed. A second resident had morbid obesity and type 2 diabetes mellitus and had a physician order to be weighed every three days, with notification required for a gain of 3 pounds or more. The resident was weighed every three days for a short period, then only monthly, with no documented weight in one month, despite a documented 20-pound gain over several months. Staff interviews showed the LVN was unaware of the three-day weight order, the nurse relied on the TAR for weight frequency, and the CNA did not notice a significant weight gain. The facility's weight policy stated residents were to be weighed by the 5th of the month, significant weight loss was to be reweighed within 24 hours, and monthly weights were to be entered by the 7th of each month.
Missing RN Coverage on Multiple Weekend Days
Penalty
Summary
The facility failed to use the services of an RN for at least eight consecutive hours a day, seven days a week on 5 of 34 days reviewed during the look-back period for weekend coverage. Record review of the facility Employee Timecards dated 08/06/25 showed no RN coverage on 04/20/25, 06/01/25, 06/21/25, 07/19/25, and 07/27/25. The report states the facility did not have RN coverage in the building for eight consecutive hours on those dates. During interview on 08/07/25, the DON stated ADON C was responsible for completing nursing schedules and that she had recently taken over schedules after ADON C left on 07/23/25. The DON said she was not aware the facility did not have RN coverage on the listed dates and that she reviewed schedules after they were completed by ADON C without realizing there was no RN. The Administrator also stated ADON C was responsible for completing nursing schedules and the DON was to review them, and confirmed she was not aware of the missing RN coverage. The Administrator stated the facility did not have a policy for RN coverage and instead followed CMS guidelines.
Pureed Menu Preparation Did Not Follow Recipe Directions
Penalty
Summary
The facility failed to ensure the menus met residents’ nutritional needs and were followed for 1 of 3 meals observed, specifically the lunch meal on 08/06/25. During observation, [NAME] D prepared the pureed lunch meal and did not follow the pureed recipes for cilantro lime chicken and rice pilaf. Instead of using the liquid directions in the recipes, [NAME] D added water twice to the chicken and twice to the rice using the processor food pusher, without measuring the amount, then added thickener and blended the items. The pureed chicken was poured into small food cups and appeared to have a mashed potato consistency, but the chicken did not appear to be fully blended. The pureed rice pilaf also appeared to have a mashed potato consistency. Interview with [NAME] D revealed she had been employed for over a month, reviewed the puree recipe to ensure she had all ingredients, and knew the recipe stated not to add water, but added water because the chicken and rice were thick and needed to be loosened. She stated she could have used chicken stock instead of water, but none was available, and that adding water could take away flavor. The Dietary Manager stated cooks were expected to follow recipes and maintain the correct food consistency, that chicken stock was available in the kitchen, and that [NAME] D failed to use it. The facility’s pureed policy stated water was never to be used as the liquid added to a pureed item and listed acceptable liquids such as broth, gravy, sauce, milk, juice, and melted margarine/butter.
Pureed Chicken Served at Incorrect Consistency
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for residents who required a pureed diet during the lunch meal. The deficiency involved pureed Cilantro Lime Chicken served on 08/06/25. The menu for that lunch service listed Cilantro Lime Chicken, pilaf, squash and red peppers, dinner roll, margarine, fruit crisp, and a beverage. During observation at 10:45 AM, [NAME] D was seen preparing the pureed lunch by placing the lime chicken in a processor, adding water twice without measuring, adding thickener, and blending the mixture for about 5-10 seconds before pouring it into small food cups. The pureed cilantro lime chicken was observed to have a mashed potato consistency but did not appear fully blended. Neither [NAME] D nor the Dietary Manager checked the consistency or ensured it was blended to a pudding smooth consistency. During the test tray observation, the pureed cilantro lime chicken did not have a smooth/pudding consistency and had bristle in it, and the Dietary Manager stated it was not the correct consistency. [NAME] D stated pureed food needed to have a smooth/mashed potatoes consistency and that she thought the chicken consistency was correct. The Dietary Manager stated the cooks were expected to follow the recipe, blend the pureed meal thoroughly, and check deboned chicken carefully to ensure there were no bristles or pieces of bones.
Failure to Include Resident and POA in Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure a resident had the right to participate in the development and implementation of her person-centered plan of care. Resident #32 was a female admitted on 08/03/23 and returned on 03/08/25. Her diagnoses included hypertension, dementia, cognitive communication deficit, and depression, and her quarterly MDS reflected severe cognitive impairment with a BIMS score of 4. Review of her care plan showed the last review/revision on 04/24/25, with a return-to-community referral category noting the POA had no desire for the resident to return to the community and that staff would revisit on comprehensive assessments only. Record review showed the last care conference was completed on 08/07/24 for an annual care conference, and there was no documentation in the progress notes regarding care plan meetings or family being made aware of them. The resident’s Family Member A/POA stated he had concerns about the resident’s care, had not been invited to any care plan meetings to address those concerns, and was not aware that meetings were held quarterly. The resident stated she had no concerns but could not recall attending a care plan meeting. The DON stated care plan meetings should be completed quarterly with family and that the Social Worker and ADON C/MDS Coordinator were responsible for coordinating them; the Administrator also stated the Social Worker and ADON C were responsible for scheduling the meetings. Both the DON and Administrator stated they were not aware the resident had not had a care plan meeting since 2024.
Failure to Report Resident Elopement and Address Exit-Seeking Behavior
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property when a resident with a history of exit-seeking behavior and a high elopement risk left the facility and was found outside near an apartment complex next to the facility. The resident had diagnoses including Alzheimer’s disease, anxiety disorder, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and unspecified lack of coordination. Her MDS reflected moderate cognitive impairment with a BIMS score of 11, and the elopement risk evaluation identified her as high risk for elopement. Record review showed the resident’s care plan did not address exit-seeking behaviors until after the event. On the morning of the incident, staff documented that the resident eloped and was missing for approximately 3 to 5 minutes before being returned by a passerby who had found her near the apartment complex. Staff interviews indicated the resident had a history of trying to leave, saying she wanted the code for the door, stating she was going with people leaving the building, and attempting to push the door. Staff also stated she moved quickly in her wheelchair and could be redirected, but they did not know exactly how she exited the facility on the day of the event. The nurse, RN, Activity Director, DON, and Administrator each described the resident being brought back by a woman from the apartment complex who had seen her outside. The resident reportedly said she was going to get her car. The DON and Administrator stated they did not report the incident to HHSC because they believed it was not reportable since the resident was gone only a few minutes and had no injuries. The Administrator stated she was the abuse coordinator responsible for reporting to HHSC, and later acknowledged that the incident should have been reported.
Failure to Report Resident Elopement as a Reportable Neglect Event
Penalty
Summary
The facility failed to ensure that an elopement involving a resident with a history of exit-seeking behavior was reported immediately to HHSC as a reportable allegation of neglect. Resident #24’s record showed diagnoses including Alzheimer’s disease, anxiety, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and lack of coordination. The resident’s MDS reflected moderate cognitive impairment with a BIMS score of 11, and the elopement risk evaluation identified the resident as high risk for elopement with a history of attempting to leave the facility and statements or threats to leave. On 08/08/25, Resident #24 left the facility and was found near an apartment complex on a busy street next to the facility by a passerby who brought the resident back. Facility documentation described the event as an elopement lasting about 3 to 5 minutes, with no new injuries noted and a head-to-toe assessment showing intact skin. Staff interviews confirmed the resident had been seen in the dining area shortly before the event, that no alarm doors were heard, and that the resident likely exited when a visitor left the building. Staff also stated the resident had a history of saying she wanted the door code, trying to leave with others, and pushing on doors. The DON and Administrator both stated they did not think the incident was reportable because the resident was gone only a few minutes and returned without injury. The Administrator, who was also the abuse coordinator, stated she did not report the incident to HHSC and had discussed it with higher-level staff and the DON before concluding it was not reportable. The facility’s abuse/reportable events policy required allegations of neglect and injury of unknown source to be reported to the administrator and then to HHSC within the required timeframes, but this elopement was not reported.
Care plan not reviewed after assessment
Penalty
Summary
The facility failed to ensure Resident #32’s comprehensive care plan was reviewed and revised by the interdisciplinary team after the resident’s assessment was completed. Record review showed the resident was a [AGE]-year-old female with an admission date of 08/03/23 and a return date of 03/08/25. Her quarterly MDS assessment reflected diagnoses of hypertension, dementia, cognitive communication deficit, and depression, and it documented severe cognitive impairment with a BIMS score of 4. The care plan was last reviewed/revised on 04/24/25, and the last care conference report showed the last care plan meeting was completed on 08/07/24 for the annual care conference. Record review found no documentation in the progress notes regarding care plan meetings or the family being made aware of care plan conference meetings. The resident’s Family Member A/POA stated he had concerns about the resident’s care, had not been invited to any care plan meetings to address those concerns, and was not aware that care plan meetings were held quarterly. The resident stated she had no concerns but could not recall attending a care plan meeting. The DON stated the Social Worker and ADON C, who was the MDS Coordinator, were responsible for coordinating care plan meetings, and the Administrator stated the IDT was responsible for conducting them. Both also stated they were not aware the resident had not had a care plan meeting since 2024.
Unattended Medication Left at Resident Bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel for one resident on one hall. Resident #26, a female with diagnoses including dysphagia, nutritional deficiency, GERD without esophagitis, anxiety disorder, depression, and hypertension, had a BIMS score of 15 indicating intact cognition. Her physician order included sucralfate 1 gram orally four times daily for GERD without esophagitis. During observation, Resident #26 was found in bed with a medication cup on the bedside table containing a white half pill, while the other half was in her mouth as she prepared to drink water. She stated the nurse had just dropped off the medication for her to take. RN B, who was assigned to the resident, stated she had provided the sucralfate and left it in the room because the resident took her time taking medications, and acknowledged she should not have left it unattended. The DON stated nurses were expected to stay in the room and observe residents take medications, and that medications should not be left unattended in rooms.
Failure to Notify POA Before Resident Transfer
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that involved the resident and the resident representative and informed them of the final discharge plan for one resident. Resident #24 was an older female admitted with diagnoses including Alzheimer’s disease, anxiety, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and lack of coordination. Her MDS reflected moderate cognitive impairment with a BIMS score of 11, and her care plan noted that the POA had no desire for her to return to the community and that staff would keep the POA updated on the plan of care. Resident #24 eloped from the facility and was placed on 1:1 supervision until discharge. On the day of discharge, nursing documentation noted the resident was calm and oriented to self, vital signs were at baseline, medications were reconciled, belongings were gathered, and the resident was en route to another facility. However, the clinical record contained no documented evidence that the legal representative or family member was notified of the discharge or involved in discharge planning before the transfer occurred. The facility’s discharge policy stated that residents and/or responsible parties would be notified prior to transfer or discharge. During interviews, the family member and POA stated they were not told about the transfer before it happened and only learned of it afterward. The family member reported receiving calls about the elopement and a voicemail about possibly moving the resident to a secure unit, but no agreement was made for discharge to another facility. The LVN stated she was not told to contact the family and did not do so before the discharge, while the DON stated she assumed someone had notified the family but was not sure. The Administrator stated she believed the family was aware, later acknowledged the transfer was not handled appropriately, and identified a lack of communication. The MD stated he approved the transfer and expected the facility to notify the family before discharge.
Missing Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident who was discharged to another nursing home on 08/11/25. The resident was an older female with diagnoses including Alzheimer's disease, anxiety disorder, depression, diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and unspecified lack of coordination. Her MDS discharge assessment reflected moderate cognitive impairment with a BIMS score of 11, and her care plan addressed return to community referral with the POA having no desire for her to return to the community. Record review showed a progress note on the day of discharge stating the resident was calm and oriented to self, vital signs were at baseline, bowel movement was reported that morning, medications were reconciled, belongings were gathered, and report was given to family and the receiving facility. However, the clinical record contained no documented discharge summary for the resident. Staff interviews reflected differing understanding of who was responsible for completing the discharge summary, and the Administrator and DON acknowledged that the discharge summary had not been completed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified during a review of the facility's records for a period from April 9, 2024, to July 15, 2024. Specifically, on nine occasions, the facility did not have RN coverage for the required duration. The dates of non-compliance were April 13, May 11, May 12, May 19, June 9, June 15, June 23, July 6, and July 7, 2024. The review of employee time cards revealed that the RNs, including RN Z and the Director of Nursing (DON), worked in shifts that did not meet the eight consecutive hours requirement, often due to breaks or lunch periods. Interviews conducted with the DON and the Administrator revealed a lack of awareness and policy regarding the consecutive RN coverage requirement. The DON, who recently assumed staffing responsibilities, was unaware of the non-compliance and speculated that the issue arose from RNs clocking out for breaks. The Administrator confirmed that the facility did not have a specific policy for RN coverage and instead relied on CMS guidelines. This oversight could potentially place residents at risk of not having their nursing and medical needs adequately met.
Failure to Label IV Medication Leads to Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles, as required by State and Federal laws. This deficiency was observed in the case of a resident who was receiving intravenous (IV) medication. The resident, a male with a diagnosis of sepsis and bacteremia, was prescribed Meropenem to be administered intravenously every eight hours. During a medication pass, the Licensed Vocational Nurse (LVN) responsible for administering the IV medication did not label the IV bag and tubing with the date, time, and her initials, as required by the facility's policy. The LVN acknowledged her failure to label the IV bag and tubing, stating that she was aware of the requirement but had forgotten to do so. She recognized that this oversight could lead to medication errors, such as overdose or omission of a dose, and posed a risk to infection control. The Director of Nursing (DON) confirmed that the expectation was for staff to date and initial IV bags and tubing to track when they were last changed. Despite the training provided, the DON could not specify the risks associated with the failure to label but noted that no adverse events had occurred yet. The facility's policy on IV administration, revised in August 2021, clearly outlined the need to verify and label IV bags and tubing with the date, time, and nurse's initials.
Failure to Accurately Report Licensed Nurse Hours
Penalty
Summary
The facility failed to comply with the mandatory submission of staffing information to CMS, specifically regarding the accurate reporting of licensed nurse hours. This deficiency was identified for eight specific days within the first quarter of the fiscal year 2024. The facility did not submit accurate licensed nurse hours for these dates, which could potentially impact the quality of care provided to residents. The CMS PBJ report indicated that the facility lacked 24-hour licensed nursing coverage on these days, although a review of staff timesheets showed that there was indeed coverage. Interviews conducted during the investigation revealed that the issue stemmed from a problem in the facility's system, which failed to pull the LVN worked hours correctly. The Corporate Analyst responsible for submitting the PBJ staffing information acknowledged the issue and stated that it had been identified and corrected in the previous quarter. The facility's Administrator was unaware of the PBJ staffing report details, as the corporate office handled the reporting. Additionally, the facility did not have a specific policy for PBJ staffing, relying instead on CMS guidelines.
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What surveyors actually found near you
We read the 928 citations issued within 25 miles in the last 12 months — including the 47 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kennedale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Oaks Nursing & Rehabilitation | 3.9 mi | ★★★★★ | 1 | 0 |
| Immanuel's Healthcare | 4.2 mi | ★★★★★ | 3 | 0 |
| Village Creek Nursing & Rehabilitation | 4.8 mi | ★★★★★ | 11 | 0 |
| Tuskegee Airmen Texas State Veterans Home | 5 mi | — | 11 | 3 |
| Matlock Place Health & Rehabilitation Center | 6 mi | ★★★★★ | 10 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.