Avir at Killeen: Call System Failure Left Resident on Floor - TX
Inspectors cited the facility for failing to provide a working call system to a resident who had ended up on the floor. The consequence, as inspectors described it, was direct: without a way to summon staff, the resident could not communicate what they needed. That failure, they wrote, could lead to a failure of care.
The facility's own written policy made the requirement plain. A call system policy updated as recently as January 2025 stated that each resident is provided with a means to call staff directly for assistance from their bed, from toileting and bathing facilities, and from the floor. The floor is named specifically. The policy existed. The call system was not there.
A second policy, on resident rights, revised in February 2021, listed among the basic rights guaranteed to every resident a dignified existence and the right to be treated with respect, kindness, and dignity.
The resident on the floor had neither.
The deficiency was classified as having minimal harm or potential for actual harm, and inspectors noted that only a few residents were affected. But the classification captures only what inspectors could document. It does not capture how long the resident was on the floor, whether anyone came, or what the resident needed while they waited.
The facility operates under the name Killeen Nursing and Rehabilitation at 5000 Thayer Drive and is identified in federal records under provider number 676438. The inspection was a complaint survey, meaning someone had reported a concern before inspectors arrived.
A call system is among the most basic tools a nursing home resident has. For people who cannot get up on their own, cannot walk to a doorway, cannot raise their voice loudly enough to be heard, the call button is the only connection between them and anyone who can help. Remove it, and the resident is alone in whatever is happening to them.
The facility's January 2025 policy update shows staff were aware of the requirement. Someone rewrote the policy four months before the inspection found it wasn't being followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Killeen from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 26, 2026 · Our methodology
Avir at Killeen in Killeen, TX was cited for violations during a health inspection on August 11, 2025.
Inspectors cited the facility for failing to provide a working call system to a resident who had ended up on the floor.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.