Avir at Coronado: Care Plan Failures for Tube-Fed Residents - TX
When federal inspectors sat down with the DON on April 23, 2026, she acknowledged she was personally responsible for updating every care plan in the facility. She acknowledged Resident 4's care plan had not been updated to reflect changes in the resident's care. She acknowledged that failing to develop, update, and implement care plans could result in a resident not getting the care they need.
Then she said Resident 4 had not had a negative outcome.
That framing, that a resident had not yet been harmed, was the facility's answer for what inspectors found during a two-day inspection completed April 24. What they found were residents with serious medical devices, a gastrostomy tube and an indwelling urinary catheter, whose documented care needs existed nowhere in their care plans.
Resident 4 was observed on April 22 at 1:30 in the afternoon during routine care. The resident was not interviewable and did not respond to direct questions. During that observation, inspectors noted a gastrostomy tube that was plugged. A gastrostomy tube is surgically placed through the abdominal wall into the stomach to deliver nutrition and medication directly when a person cannot swallow adequately. Keeping it patent, meaning open and functional, requires regular flushing. Physician orders for Resident 4 called for flushing the tube with 30 milliliters of fluid every 12 hours as needed.
There was no focus, no goal, and no intervention related to flushing that tube anywhere in Resident 4's comprehensive care plan.
The DON told inspectors Resident 4 had not experienced significant weight loss since admission and was eating from the kitchen and taking medications orally. But the physician order for tube flushing was still active. The tube was still there. And the care plan still said nothing about it.
Resident 33 was a cognitively intact woman, scoring a perfect 15 on the cognitive assessment used to measure memory and thinking. She knew where she was. She could answer questions. Her records showed she was admitted for neuromuscular dysfunction of the bladder, a condition in which the bladder does not function properly due to damage to the nervous system, along with a urinary tract infection. Because of that diagnosis, she had an indwelling catheter, a tube inserted to continuously drain urine from the bladder, and a physician order to change it every 24 hours as needed. A separate order, dated February 20, 2026, required staff to monitor her urinary output every shift.
Her comprehensive care plan, reviewed on April 24, contained no focus, no goal, and no interventions related to catheter care.
The registered charge nurse who spoke with inspectors on April 23 did not dispute this. She said she expected comprehensive care plans to have all care needs present. She said not having completed care plans could disrupt continuity of care for residents. She said she had identified issues with the care plans and had come up with an action plan in March.
March was five weeks before the inspection.
The action plan had not been implemented. She attributed the problem to changes in leadership nurses and staff turnover.
What that means practically is this: a staff member coming on shift for the first time, or covering for someone who called out, would open Resident 33's care plan and find nothing about her catheter. No instruction to monitor output. No guidance on when to change the device. No documentation that this was even part of her care. The same would be true for whoever was responsible for flushing Resident 4's gastrostomy tube.
Care plans exist precisely because nursing homes run on rotating staff. The same resident may be seen by a dozen different aides and nurses over the course of a week. The care plan is the document that makes care consistent regardless of who shows up. When it is incomplete, the continuity the facility promised the resident and her family does not exist on paper, and may not exist in practice.
The facility's own policy, last revised in March 2022, states that care plans must include measurable objectives and timeframes, describe the services to be provided to maintain each resident's highest practicable physical and mental well-being, and be revised whenever a resident's condition changes. The policy specifically names the interdisciplinary team as responsible for reviewing and updating care plans at least quarterly.
Resident 33's admission assessment was dated March 5, 2026. Her catheter care order had been in place since at least February. By April 24, no one on the interdisciplinary team had documented a single goal or intervention related to the device draining her urine.
The charge nurse said leadership changes and turnover drove the failures. The DON said she was responsible and should have acted. Neither offered a timeline for when the gap would be closed.
Inspectors classified both deficiencies under the same tag, with a finding of minimal harm or potential for actual harm affecting some residents. No immediate jeopardy was cited. The violations did not rise to the level that triggers emergency action under federal oversight rules.
Resident 33 knew exactly what care she needed. She had a perfect cognitive score. Whether anyone told her that the document guiding her care had left out the tube keeping her bladder functioning, the inspection report does not say.
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 16, 2026 · Our methodology
Avir at Coronado in ABILENE, TX was cited for violations during a health inspection on April 24, 2026.
When federal inspectors sat down with the DON on April 23, 2026, she acknowledged she was personally responsible for updating every care plan in the facility.
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.