Avir at Kingsland: Psychotropic Drugs Without Consent - TX
The woman, identified in inspection records only as Resident 1, was admitted to Avir at Kingsland following a fall and surgical repair of a fractured left femur. She was in her later years, dealing with dementia, chronic heart failure, acute kidney failure, a history of falls, and a handful of other serious conditions. Starting March 31, 2026, she was given 50 milligrams of trazodone each night, listed in her orders as a treatment for insomnia, and 25 milligrams of quetiapine, the generic form of Seroquel, listed as a treatment for depression. She had neither diagnosis.
When a federal inspector called the prescribing physician on May 28, 2026, he said he prescribed quite a bit of psychiatric medication for dementia behaviors. He said consent was the facility's responsibility, not his. He agreed that trazodone, Seroquel, and Depakote were among the medications that required signed consent before being given to a resident.
Then the inspector asked him directly about the orders for Resident 1.
"I would never treat depression with Seroquel," he said. He acknowledged that Seroquel and quetiapine are the same drug. He said if the order listed quetiapine as a treatment for depression, it was entered wrong. He said he reviews verbal orders in the facility's electronic records system before signing them, and that he may have missed the error. He did not explain why the medication had been prescribed without a matching diagnosis. He said he needed to get back to work and ended the call before the interview was complete.
The second resident named in the inspection, identified as Resident 2, had a family member who told inspectors he had never consented to any psychotropic medications being given to her at all. He said during his visits she had been alert, awake, sometimes in bed, sometimes at a table in the day room. He had not seen her heavily sedated or sleeping through the day. He said the facility had called him about falls before, but nothing serious enough to require hospitalization.
Her family member's account of her condition, and his account of what he was never told, sit in the inspection record side by side with no resolution. The facility's own resident rights policy, last revised in February 2021, states that residents have the right to be free from chemical restraints not required to treat their symptoms and the right to be informed of and to participate in their care planning and treatment.
Quetiapine is an antipsychotic. In older adults with dementia, it carries a black-box warning from the Food and Drug Administration for increased risk of death. Trazodone is a sedating antidepressant frequently used as a sleep aid in nursing home settings, sometimes without rigorous documentation of the underlying condition it's meant to address. Neither of those facts appears in the inspection narrative. What does appear is a physician who prescribed one of those drugs for a condition he says he would never use it to treat, and who could not explain, before hanging up, why a patient with dementia and a fractured hip had been receiving it every night for nearly two months.
Resident 1 was discharged from Avir at Kingsland on May 26, 2026, two days before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Kingsland from 2026-05-28 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 8, 2026 · Our methodology
Avir at Kingsland in Kingsland, TX was cited for violations during a health inspection on May 28, 2026.
She was in her later years, dealing with dementia, chronic heart failure, acute kidney failure, a history of falls, and a handful of other serious conditions.
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.