Avir at Coronado: Dignity Violations in Colostomy Care - TX
The bag belonged to Resident 67, a woman whose colostomy required a one-piece appliance that nursing staff changed every three days. The bag inspectors found was 90 percent air, according to the Director of Nursing, who was present during the inspection. Standard medical guidance holds that a colostomy bag should be emptied when it reaches one-third capacity, to prevent the baseplate from peeling away from the skin and to stop leaks.
Nobody had emptied it.
The Director of Nursing told inspectors that all nursing staff were responsible for monitoring the contents of collection bags and that bags were supposed to be checked every two hours during rounds, and at least once per shift. She said certified nursing assistants were permitted to empty bags and assist with routine ostomy care. She also said skills checkoffs for colostomy and urinary catheter care were completed annually, meaning staff had been trained and evaluated on exactly this task.
When inspectors raised the question of what harm a neglected bag causes, the Director of Nursing framed it as a dignity issue. She said a resident "may not feel as pretty, or may feel self-conscious." She denied that Resident 67 had ever reported pain or discomfort from stool accumulating in the bag.
The facility's own dignity policy, last revised in February 2021, prohibits demeaning practices and standards of care that compromise residents' dignity. It specifically lists helping residents keep urinary catheter bags covered as an example of promoting dignity. The colostomy policy, updated just two months before the inspection in February 2026, confirmed that CNAs could empty bags and assist with routine care.
The gap between what the policies required and what inspectors found was not subtle. A bag checked every two hours by trained staff should not reach 90 percent capacity with stool adhering to its inner surface. That kind of accumulation takes time.
The Director of Nursing's explanation for what she expected of staff was direct: "keep an eye on it" and "know their resident's needs." What inspectors documented suggested neither had happened.
Resident 67 had been living with a colostomy, a surgically created opening in the abdomen that routes waste into an external bag worn against the skin. When a colostomy bag overfills, the baseplate, the adhesive seal that keeps the bag pressed against the skin around the stoma, can begin to lift. That separation creates the conditions for leakage onto the skin and clothing. The longer the bag goes unemptied, the greater the pressure on that seal.
The inspection classified the violation as causing minimal harm or potential for actual harm, and noted that some residents were affected. The facility was cited under the federal requirement that residents be treated with dignity.
Inspectors noted they had assisted the resident in changing her shirt during the visit, a detail that appears without further explanation in the report. It suggests the condition of the bag had already affected her clothing by the time anyone intervened.
The Director of Nursing said her expectations were clear. Staff knew the standard. The checkoffs had been done. And still, when federal inspectors walked into that room, a woman sat with a colostomy bag stretched past the point where it should have been emptied, stool pressed against the plastic, waiting for someone to notice.
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 15, 2026 · Our methodology
Avir at Coronado in ABILENE, TX was cited for violations during a health inspection on April 24, 2026.
The bag belonged to Resident 67, a woman whose colostomy required a one-piece appliance that nursing staff changed every three days.
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.