Avir at Coronado: Catheter Care Documentation Failures - TX
The inspection, completed April 24, 2026, centered on Resident 33. Inspectors found the catheter had never been added to the resident's care plan. Without it there, nurses and aides had no formal, documented direction for how to manage it. The director of nursing told inspectors she didn't believe that had caused any negative outcome, because staff could look at physician orders and the medication administration record instead. She said she was responsible for updating care plans and monitoring what nurses documented. She also said she was only one person and couldn't monitor everything while also helping on the floor.
The documentation gaps were hard to dismiss. There were no recorded urine outputs in the medication administration record on April 9, April 14, or April 19. Aides were supposed to empty the catheter bags and report the output to nurses, who would then document it. The director of nursing said that if outputs weren't documented, she couldn't prove the bags had been emptied or the outputs measured at all. She said she would have expected a progress note explaining the missing entries. There were none.
Then, on April 22, the catheter started leaking.
The director of nursing explained what had happened: the catheter had a second port, designed for an additional bag to be connected, and nothing had been secured to it. Urine was leaking from that open port. She removed the catheter herself. She told inspectors that catheters could also leak when the tubing wasn't secured and got pulled during transfers or resident care — exactly the risk that a leg strap is meant to prevent. The securement device, the strap that holds the tubing against the inner thigh to reduce friction and movement at the insertion site, wasn't there.
Neither was the privacy bag. The director of nursing acknowledged that without one, other residents and visitors could see the urine in the bag. She said not having the securement device could cause the tubing to become loose if pulled during care. She said she did not believe either absence was connected to the catheter not being on the care plan.
The facility's own catheter care policy, dated July 2024, was direct on all of it. If leakage occurs, replace the catheter using sterile technique. Maintain an accurate daily record of output. Keep the catheter secured with a leg strap to the resident's inner thigh. Document the date and time care was given, who gave it, and all assessment findings.
On the question of why the outputs went unrecorded on three separate days spread across two weeks, the director of nursing said, in a follow-up interview the day after the inspection, that she did not know.
Resident 33 had a catheter that leaked, wasn't strapped down, wasn't shielded from view, wasn't on any care plan directing how it should be managed, and had stretches of days where no one recorded whether the bag was ever emptied. The director of nursing's explanation for the sum of it was that she was one person, and she couldn't watch everything.
What she could not say was whether anyone had checked on Resident 33 on any of those three days when the record showed nothing.
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.
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: August 17, 2026 · Our methodology
Avir at Coronado in ABILENE, TX was cited for violations during a health inspection on April 24, 2026.
The inspection, completed April 24, 2026, centered on Resident 33.
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.