Avir at Coronado: MDS Assessment Error for Stroke Patient - TX
Federal inspectors who visited Avir at Coronado on April 24 found that the facility's admission assessment for a resident identified only as Resident #4, a woman admitted earlier this year with dysphagia and a nontraumatic cerebral hemorrhage, contained errors significant enough to affect her care planning. The Minimum Data Set assessment, completed March 14, recorded the wrong information about her eating status and omitted documentation of clinically important conditions. The woman's care plan reflected none of it.
The MDS is the foundation of nursing home care. Every intervention, every therapy, every dietary order, every safety protocol for a resident flows from what that document says about them. Get it wrong, and the care plan built on top of it is built on nothing.
Resident #4's assessment recorded her eating status as requiring partial to moderate assistance to bring food to her mouth and swallow. That notation describes someone who eats by mouth. She didn't. She had a gastrostomy tube, a G-tube, in place since the day she arrived. A physician order dated April 23, just one day before inspectors arrived, directed staff to monitor and flush the unused tube every 12 hours. The tube hadn't been used for feeding. Her regular diet was listed as mechanical soft with regular liquid consistency, a texture-modified oral diet for someone with swallowing difficulty. The MDS said she was eating by mouth with some help. The physician orders said her G-tube was sitting dormant and needed to be flushed.
She also had a BIMS score of zero on that same assessment, the lowest possible score, indicating severe cognitive impairment. She could not advocate for herself, flag errors in her own chart, or tell anyone that something was wrong.
The assessment also documented that she had lost 5 percent or more of her body weight in the last month, or 10 percent or more in the last six months. A weight loss of that magnitude in a severely cognitively impaired patient who cannot eat normally is a clinical red flag. It belongs in a care plan. It didn't appear there. Inspectors reviewed Resident #4's comprehensive care plan on the day of the visit and found no focus area, no goal, and no interventions related to weight loss or gastrostomy tube feedings.
When inspectors interviewed the MDS coordinator at 9:30 that morning, she acknowledged the problem directly. She said she was responsible for completing MDS assessments. She said she answered the questions to the best of her ability. She said she made a mistake in the documentation when she did the MDS. She said she did not believe any negative effect had occurred to Resident #4 as a result of the incorrect coding. She said she had mistakenly coded the assessment incorrectly. She said she monitored MDS assessments for accuracy. She said she used the RAI manual as her reference guide, and that a link to it was available directly within her computer program.
The director of nursing, interviewed the day before at 1:00 p.m., said the MDS coordinator was responsible for assessments. Her expectation, she said, was that they be completed in a timely manner and be accurate.
There is a gap between that expectation and what the inspection found. The admission MDS for a severely cognitively impaired stroke patient who had been tube-fed since arrival recorded her as someone eating by mouth. The weight loss that should have generated a care plan goal did not. Nobody caught it before April 24.
The facility's own policy on resident assessments, last revised in March 2026, one month before the inspection, assigns the resident assessment coordinator responsibility for ensuring the interdisciplinary team conducts timely and appropriate assessments. The policy lists the full range of required assessments under federal OBRA requirements, from admission through discharge. It cites the RAI User's Manual as the governing reference. The MDS coordinator said she had that manual a click away.
CMS rated this deficiency at the level of minimal harm or potential for actual harm, affecting a small number of residents. One resident was cited in the finding. The inspection covered 19 residents reviewed for assessment accuracy.
What the rating doesn't capture is the specific situation of the woman at the center of it. She had a brain bleed. She had severe cognitive impairment. She had difficulty swallowing. She had lost a meaningful amount of weight. She had a tube in her stomach. She was entirely dependent on the people caring for her to know all of that, to have it written down correctly, and to build a plan around it. The document that was supposed to hold all of that information held something else instead, a description of a different kind of patient entirely, one who could pick up a fork.
The MDS coordinator said she didn't believe the error harmed her. The care plan had no entry for her weight loss or her tube.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Coronado from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Avir at Coronado in Abilene, TX was cited for violations during a health inspection on April 24, 2026.
The woman's care plan reflected none of it.
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.