Avir at Kerrville: Abuse Probe Never Filed - TX
The resident was a woman with severe cognitive impairment, scoring a 5 out of 15 on a standardized memory and thinking assessment that places her in the range of the most profoundly affected nursing home residents. She had Alzheimer's disease, age-related osteoporosis with fractures, and anxiety. She needed help transferring from her chair to her bed, from her bed to the toilet. She had been at the facility since February 2026.
On or around February 19, 2026, someone reported to the facility that staff members had blown cigarette smoke toward the resident and her family while they were together in the facility's designated smoking area. The facility administrator at the time filed an Incident Investigation Worksheet and reported the allegation to Texas Health and Human Services Commission. That part happened. What was supposed to come next did not.
Texas requires nursing homes to submit a formal Provider Investigation Report, known as a 3613-A, within five days of any abuse allegation. The report is supposed to describe the results of a full investigation and document any corrective action taken if the allegation was confirmed. Inspectors who visited Avir at Kerrville on April 24, 2026, looked for that report. There was none in the facility's files. They checked the Texas Unified Licensure Information Portal, the state's centralized database where these reports are supposed to appear. Nothing was there either.
The investigation itself, to the extent one existed at all, consisted of a single nursing note.
LVN-D, a licensed vocational nurse who no longer worked at the facility by the time inspectors arrived, had written a progress note on February 19, 2026, documenting that both the resident and a family member denied that staff had blown cigarette smoke at them. That was the entry. That was the record of what the facility did in response to an allegation that a cognitively impaired resident had been subjected to deliberate, directed smoke exposure by the people paid to care for her.
When inspectors interviewed LVN-D on April 23, 2026, she said she could not recall which CNAs had been smoking cigarettes that day. She confirmed she had spoken with the resident and the family member, and that both had denied the allegation. She offered nothing else. There was no documentation that anyone had interviewed the staff members who were present in the smoking area. No witness statements. No names of employees questioned. No timeline of what happened or who reported it. No corrective action. No follow-up.
The administrator who was in charge when the allegation was made in February was gone by April. The administrator who spoke with inspectors said he had not started at the facility until March 2026, so he had no firsthand knowledge of what happened to this resident or what the previous administrator had done. He said he had searched everything he could find, including the computers and files the previous administrator had used. The Provider Investigation Report 3613-A was not there. He acknowledged directly that the previous administrator should have conducted a thorough investigation and submitted the report to Texas HHSC within five days.
That acknowledgment, frank as it was, did not change what the record showed. A woman with Alzheimer's disease, a woman who could not reliably communicate or advocate for herself, had been the subject of an abuse allegation. The facility reported it to the state, then stopped.
The question of whether the allegation was true was never seriously pursued. The facility's own policy, revised in September 2022, states that all allegations are thoroughly investigated, that the administrator initiates investigations, and that a follow-up report must be provided within five days with sufficient information to describe the results and indicate any corrective action. The facility's policy said one thing. The file said another. The state database said nothing at all.
It is worth pausing on what the allegation described. This was not a claim of a medication error or a missed meal or a fall that went undocumented. The allegation was that a staff member, in a facility where residents depend entirely on workers for their safety and basic dignity, deliberately blew cigarette smoke at a resident and her family. The resident had a BIMS score of 5. She had Alzheimer's. She had anxiety. She had fractures from bones weakened by age. She was not in a position to file a complaint, seek a different facility, or protect herself from anyone who might wish to harm or demean her.
The family had been there. A family member was present when it allegedly happened. And yet when LVN-D interviewed the resident and the family member on February 19, both denied it. That denial became the entire record. No one appears to have asked who made the original report. No one documented whether the person who reported the incident was interviewed. No one identified which staff members were in the smoking area and asked them what they saw or did.
The resident was discharged home sometime after her admission in February. By the time inspectors arrived in April, she was gone. The staff nurse who wrote the only documentation was also gone. The administrator who oversaw the response to the allegation was gone. What remained was a single progress note, an empty slot in the state database where a formal investigation report should have been, and a facility policy that described a process that was not followed.
Inspectors cited the failure as causing minimal harm or the potential for actual harm. The citation covered one resident out of five reviewed for abuse-related concerns.
The current administrator, to his credit, did not minimize what the record showed. He told inspectors plainly that a thorough investigation should have been conducted and that the 3613-A should have been filed. He said the failure to do so could prevent the identification of possible abuse or neglect.
He was right. It also meant that whatever happened in that smoking area on a February afternoon, between a group of staff members and a woman with severe dementia and her family, will likely never be fully known.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Kerrville 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 Kerrville in Kerrville, TX was cited for abuse-related violations during a health inspection on April 24, 2026.
She had Alzheimer's disease, age-related osteoporosis with fractures, and anxiety.
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.