Avir At Coronado

During an interview on 04/23/2026 at 1:06 p.m., the AD stated she attended Resident Council meetings and was invited to the meetings by the resident council members.

She stated the council liked her writing the minutes about the meetings for them.

She stated she would then write concerns on a grievance form and give the grievance form to the ADMN.

She stated she had not gotten any form of resolution back in writing or verbally after she gave the grievance form to the ADMN.

She stated she did not know how the information should be relayed to the resident council members.

She stated she recently kept a copy of the grievance forms and would give two copies to the ADMN so that he could give one to the department head that the grievance involved.

She stated the resident council should get notified about what was done to correct their grievances so that they felt their concerns were heard.

During an interview on 04/24/2026 at 8:25 a.m., the ADMN stated he was responsible for grievances at the facility. He stated he received the resident council's grievances from the AD. He stated he would get with the department head that the grievance was about and work with them to resolve the issue. He stated sometimes he would attempt to figure out who had made the grievance and notify them about the resolution. He stated he had gotten back to the Resident Council President before but did not address the resident council because he was not invited to those meetings. He stated the grievances were voiced in the managers' meetings and the AD was present for those. He stated he expected the AD to relay the resident council's grievance resolutions to the council members.

Record review of facility's policy titled, Resident Council, dated February 2021, reflected, The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff.6. A Resident Council Response Form will be utilized to track issues and their resolution.

The facility department related to any issues will be responsible for addressing the item(s) of concern.

Record review of the facility's policy titled, Grievances/Complaints, Filing, dated April 2017, reflected, 12.

The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a.

The administrator, or his or her designee, will make such reports orally within _____ working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

During an interview on 04/24/2026 at 9:55 a.m., the DON stated the mattresses were being replaced when the staff found a new one.

She stated a potential negative outcome was that the mattresses were not comfortable and infection control risk.

Record review on 04/23/2026 of estimate to correct hot water issue, dated 04/08/2026, reflected scope of work included remove existing receptacle, wiring, and box.

Relocate to above water heater as to be accessible.

Install new box, wiring, and receptacle.

Provide new cord set to connect water heater.

Excludes any drywall repair, paint, etc.

Record review on 04/24/2026 of facility policy titled Homelike Environment, dated February 2021, reflected The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

These characteristics include: a. clean, sanitary and orderly environment.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

The facility failed to ensure the

could place residents at risk of not receiving the proper care and services due to inaccurate assessment records.

Findings included:

Record review of Resident #4's electronic face sheet, dated 04/24/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included dysphagia (difficulty swallowing) and nontraumatic cerebral hemorrhage (a type of stroke caused by bleeding in the brain).

Record review of Resident #4's admission MDS assessment, dated 03/14/2026,0n 04/24/2026 reflected a BIMS score of 00 indicating she was severely cognitively impaired.

Further review reflected Resident #4 had gastrostomy tube (a tube placed directly in the stomach through the abdominal wall to deliver nutrition, fluids and medications , or to drain the stomach contents) since admission.

The MDS assessment documented the resident had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.

The MDS documented, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as partial to moderate assistance.

Record review of Resident #4's Physician Orders, dated 04/23/2026, reflected an order with a start date of 4/21/2026 to monitor and assess non-used gastrostomy tube (a tube placed directly into the stomach to deliver nutrition, fluids and medication and flush every 12 hours with 30 milliliters of fluid every 12 hours as needed.

The resident's regular diet was Mechanical Soft texture, Regular consistency.

Record review of Resident #33's Comprehensive Care Plan on 04/24/2026 reflected no focus, goal, or interventions related to weight loss or gastrostomy tube feedings.

During an interview on 04/24/2026 at 9:30 a.m., the MDS coordinator stated she was responsible for MDS assessments.

She stated she answered MDS assessment questions to the best of her ability.

The MDS coordinator stated she made a mistake in the documentation when she did the MDS.

The MDS coordinator stated she did not believe any negative effect occurred to the resident #4 from coding MDS assessment incorrectly for weight loss.

She stated she had mistakenly coded the assessment incorrectly.

She stated she monitored that MDS assessments were correct.

She stated she referred to the RAI manual when she had questions regarding documentation for the MDS.

The MDS coordinator stated she could refer directly to the RAI manual for any questions that she might have through a link in her computer program for completing the MDS.

During an interview on 04/23/2026 at 1:00 p.m., the DON stated the MDS coordinator was responsible for MDS assessments.

She stated her expectation was for the MDS assessment to be completed in a timely manner and for them to be accurate.

Record review of the Policy titled Resident Assessment date revised 3/2026 stated in part. 1.

The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments - conducted for all residents in the facility:(1) admission Assessment (Comprehensive);(2) Quarterly Assessment;(3) Annual Assessment (Comprehensive);(4) Significant Change in Status Assessment (SCSA) (Comprehensive);(5) Significant Correction to Prior Comprehensive Assessment (SCPA) (Comprehensive);(6) Significant Correction to Prior Quarterly Assessment (SCQA); and(7) Discharge Assessment (return anticipated and return not anticipated).b. PPS required assessments - conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits:(1) 5-day Assessment;(2) Interim Payment Assessment; and(3) Part A PPS Discharge Assessment.2.

The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments.3. A comprehensive assessment includes:a. completion of the Minimum Data Set (MDS);b. completion of the care area assessment (CAA) process; andc. development of the comprehensive care plan.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

During an interview with the DON on 04/23/2026 at 2:00 p.m. she stated she was responsible for updating resident care plans and she should have updated Resident 4's care plan to reflect the changes in his care.

She stated she was responsible for all the care plans in the facility and Resident #4 had not had a negative outcome due to the failure to update her care plan.

She stated failure to develop, update, and implement care plans could result in a resident not getting the care they need.

She stated Resident #4 had not had a significant weight loss since admission and was eating a diet from the kitchen and taking her medication orally.

Resident #33

Record review of Resident #33's electronic face sheet, dated 04/24/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] for diagnosis including neuromuscular dysfunction of bladder (urinary bladder does not function properly due to trauma, disease, or injury to the nervous system), and UTI (bladder infection).

Record review of Resident #33's admission MDS assessment, dated 03/05/2026, reflected a BIMS score of 15 indicating she was cognitively intact.

Further review reflected Resident #33 had an indwelling catheter (tube to drain urine from the bladder) and was always incontinent of bowel movement.

Record review of Resident #33's Physician Orders, dated 04/22/2026, reflected an order to change foley catheter every 24 hours as needed for neuromuscular dysfunction of bladder.

Further review reflected an order dated 02/20/2026 to monitor urinary output every shift related to neuromuscular dysfunction of bladder.

Record review of Resident #33's Comprehensive Care Plan on 04/24/2026 reflected no focus, goal, or interventions related to foley catheter care.

During an interview on 04/23/2026 at 6:24 p.m., the RCN stated she expected comprehensive care plans to have all care needs present.

She stated changes in leadership nurses and turn over in staff had led to the care plan issues.

She stated she did monitor the DON and care plans and had identified issues with the care plans but had not been able to implement her action plan she had come up with in March.

She stated not having completed comprehensive care plans could disrupt continuity of care for the residents.

Record review on 4/24/26 of the facility's policy titled: Care Plans - Comprehensive Person Centered dated revised March 2022, revealed the following: The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; any specialized services to be provided as a result of PASARR recommendations; and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.

Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

During a follow-up interview on 04/23/2026 at 5:40 p.m., the DON stated urine output should be documented on the MAR when a resident had a indwelling urinary catheter.

She stated she did not know why the output was not documented on certain days.

She stated she would expect for a progress note to be in the system to explain why no output documented.

She stated she did not believe any negative outcome had occurred from the indwelling urinary catheter not being on Resident #33's care plan because nurses looked at physician orders and the MAR to determine care needed.

She denied the indwelling urinary catheter privacy bag or securement device not being present would be because those items had not been care planned.

She stated not having a privacy bag could cause the resident to be embarrassed from other residents and visitors seeing urine in bag.

She stated not having the securement device could cause the catheter tubing to become loose if the tubing was being pulled during resident care.

She stated she was responsible for updating the care plans monitored by the RCN.

She stated she monitored the nurses documented tasks on the MAR after they had performed the tasks and completed the tasks.

She stated she was only one person and could not monitor everything along with helping on the floor to provide resident care.

Record review of the facility policy, Catheter Care, Urinary dated July 2024, reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections.If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered.Maintain an accurate record of the resident's daily output, per facility policy and procedure.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.).Documentation The following information should be recorded in the resident's medical record: 1.

The date and time that catheter care was given. 2.

The name and title of the individual(s) giving the catheter care. 3.

All assessment data obtained when giving catheter care.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026.This failure leaves residents without the nursing administrative oversight that only the DON can provide.Findings include:

During an interview on 04/23/2026 at 5:40 p.m., the DON stated she was falling behind on monitoring the nurses had performed their assessments and making sure the care plans were updated because she was having to work at night as a CNA and nurse to fill in open shifts.

She stated she knew that she was not supposed to serve as a charge nurse when there were more than 60 residents but there were times when they did not have any other staff able to fill in the unassigned shifts.

During an interview on 04/23/2026 at 6:24 p.m., the RCN stated the DON was getting behind on the comprehensive care plans.

She stated changes in leadership nurses and turnover staff had led to the DON having to work on the floor as a nurse and CNA at times.

She stated she was aware the DON should not work as a charge nurse when there were over 60 residents in the facility.

She stated the DON not being able to monitor the nurses were performing assessments and making sure the care plans were updated could disrupt resident care.

During an interview on 04/24/2026 at 8:25 a.m., the ADMN stated he was aware that the DON had been working on the floor helping fill in open CNA and nursing shifts.

The ADMN stated he was responsible for ensuring the staff positions were filled. He stated he had attempted to hire nurses and CNAs. He stated the obstacle in filling the CNA and nursing positions were that the facility could not offer competitive wages as other nursing homes in the area. He stated he has lost staff members in the last couple of months and was trying to hire more. He stated the facility had over 60 residents and the DON should not be working on the floor as a CNA or charge nurse, but it was better to have the shifts filled to perform resident care.Review of daily staffing schedule revealed DON worked as a charge nurse on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026.

Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated August 2022, reflected: The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

Observation of food preparation and service in the kitchen on 4/21/26 at 11:21 am revealed that the facility failed to have enough refried beans or a comparable substitute which resulted in 21 residents not receiving refried beans.

After 17 residents were served their tray without refried beans, the Dietary Manager provided rice to the 4 last trays/residents. In an interview on 4/21/26 at 12:00 pm, the DM said there were 53 residents who received a regular diet.

She was going to try to find out who the residents were who did not receive refried beans and give them some rice. In an interview on 4/22/26 at 2:49 pm, the Dietician said that rice was not an appropriate substitute for refried beans and she would not have approved that substitution.

She said that when the kitchen runs out of food, a nutritional equivalent substitute should be provided.

The Dietician said when she visits the facility, they review the substitution log.

The Dietician said the failure had the potential for residents not to have their nutritional needs met. In an interview and record review on 4/23/26 at 10:18 am, the DM said she did not know why they ran out of refried beans.

The menus were followed for the number of residents they were serving, and the correct portion size was used.

The DM said she did not know why when they ran out of refried beans, a substitute wasn't provided at that time.

The DM was asked if rice was a comparable nutritional substitute for refried beans, she said she was not sure and that she should have called the Dietician before she made the substitute.

Record review of the substitution log for April 2026 was blank.

The DM said she had not filled it out yet for the month.

The DM said the failure had the potential for residents not to have their nutritional needs met. In an interview on 4/23/26 at 10:52 am, the DON said the nurses check each resident's tray before it was served to make sure they were getting the right textures.

They depend on the kitchen to make sure they were receiving the correct calories.

She said a potential negative outcome would be residents would have weight loss.

The DON said there were no residents identified that was having weight loss related to food or food portions served. In an interview on 4/23/26 at 2:44 pm, the ADMN said the kitchen prepared the correct amount of refried beans, as the menu shows the correct amount to make for the facility census.

They must have given the residents too large of a portion of refried beans. He said they went back and found the residents who did not receive the refried beans on their tray and gave them rice.

Record review of CMS-802 Resident Matrix, dated 4/21/26, revealed there were no residents identified as having excessive weight loss, except for one resident whose excessive weight loss was unrelated to nutrition.

Record review of the facility policy Substitutions, dated as revised April 2007, revealed the following [in part]: Policy Statement: Food substitutions will be made as appropriate or necessary.Policy Interpretation and Implementation:1.

The food service manager, in conjunction with the clinical dietician, may make food substitutions as appropriate or necessary.

The food services shift supervisor on duty will make substitutions only when unavoidable. 2.

The food services manager will maintain an exchange list identifying the seven (7) exchanges of food groups.

When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making the substitution.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

serve food in accordance with professional standards.

serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as

from dirt and food crumbs. B.

The stand that the mixer was on was clean and free from dirt and food crumbs. C.

The plastic container that contained the food thickener was free from spilled food and not soiled. D.

The convection oven and stove were clean on the inside and outside. E.

The shelf above the stove was clean and not soiled with food crumbs and dust. F.

The refrigerator was clean and free of food crumbs and dust. G.

The stand that held the residents' plates was clean and free of food crumbs.

These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.In an observation on 4/21/26 at 9:13 am, during the initial tour of kitchen, the floors throughout the kitchen were soiled with dirt and food crumbs especially around the baseboards of the kitchen.

The stand that the mixer was on was soiled with dirt and food crumbs and underneath the stand there was a food thickener or flour in a pile.

The plastic container that contained the food thickener had spilled dried food and dust on the outside of the container with a plastic scoop lying on the top of the container.

The convection oven and the stove had dried baked on food on the inside and grease and dust on the outside of the appliances. On top of the convection oven there were additional oven shelves that were covered with old baked food and grease.

The shelf above the stove was soiled with food crumbs and dust.

The bottom shelf of the refrigerator was soiled with food crumbs.

The stand that held the resident's plates was soiled with had food crumbs. In an interview on 4/23/26 at 2:05 pm, the findings of the initial tour were discussed with the DM.

She said that it was her expectation for the kitchen to be clean after every meal.

The DM said potential negative outcomes of not keeping the kitchen free of food crumbs, and dirt/dust could attract pests and lead to sickness. In an interview on 04/23/2026 at 2:44 pm, the ADMN said it was his expectation for the kitchen to be clean. A policy regarding kitchen sanitization was requested but not provided by time of exit from the Dietary Manager on 4/23/2026 at 2:05 pm.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

establishes the criteria, process, documentation requirements, and follow-up procedures for

hospitalizations.READMISSION.On Return (within 4 hours): Assessment, med reconciliation, infection

and Competent Nursing dated August 2022, reflected: Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs.

675746 04/24/2026

Avir at Coronado 1751 N 15th St Abilene, TX 79603

Findings included:

During an interview on 04/23/2026 at 09:30 a.m., the SSD stated she was working to get her license in the state of Texas.

She stated she had a master's degree in social work from [NAME] Rico and then was licensed in the state of New York.

She stated she was working with the state of Texas to get reciprocity (licensure by endorsement) but was not licensed at this time.

She stated she had been working for the facility performing Social Work duties since December of

• She stated she had corporate support, but she did not come to the facility and all

communication was over the phone or virtual.

During a telephone interview on 04/23/2026 at 6:34 p.m., the VP of HR stated she was unfamiliar with the regulations for a Social Worker in the state of Texas and would have to review regulations before she could answer any questions about whether they needed to be licensed.

During an interview on 04/24/2026 at 8:18 a.m., the ADMN stated his expectation was to have a full-time social worker that was licensed. He stated the SSD was working on getting her license transferred to the state of Texas and she was one of the best Social Service employees he has ever worked with. He stated she only had to take a test to become licensed in Texas. He stated no other SW was in the building to perform SW duties, but the SSD did have corporate oversite. He stated he did not see any negative effect on the residents and felt that the SSD was going above and beyond for the residents at the facility.

The ADMN stated he was responsible for ensuring the staff positions were filled.

Record review of the job description for Social Services, dated 12/12/2025, reflected Licensure preferred.

Record review of the job posting for Social Services Director, no date, reflected Licensure required.

Record review of the facility policy titled, Social Services dated September 2021, reflected Not all medically-related social services are provided by a qualified social worker.

However, the facility is responsible for ensuring that all residents are provided these services whether by a staff member or through referrals to an outside agency.

Record review of Form 3740 titled Bed Classification dated 04/24/2026 revealed the facility had a licensed capacity of 188 resident beds.