Avir At Cotulla
Avir at Cotulla in Cotulla, TX — inspection on January 8, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 noted in section N: Medications in section N0415: High-Risk Drug Classes: Use and Indication states 1. Is taking: check if the resident is taking any medications by pharmacologic classification, not how it is used, during the last 7 days.
Further review shows section N0415B2.
Antidepressant : Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period.
Record review of an email from the Administrator on 01/08/2026 at 11:55 AM, documented the Administrator stated there was no MDS policy, they follow the RAI manual.
Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 noted in section J0100: Pain Management, the definition of scheduled pain medication regimen as Pain medication order that defines dose and specific time interval for pain medication administration.
For example, 'once a day,' 'every 12 hours.' Further review of the RAI noted in Section I: Active Diagnoses that One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. and Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
676288 01/08/2026
Avir at Cotulla 369 Mars Dr Cotulla, TX 78014
nurses on a full time basis.
Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, of the 6-month review period for (25
required RN coverage for 25 days between July 2025 to December 2025.The dates are: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.
Findings included:Record review of CMS CASPER Report (a confidential, that analyzes internal data to measure the quality of patient care) reflected the facility prompted for no RN hours for FY 4th Quarter 2025 (July 2025 to September 2025), for the following dates: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025.
Record review of the facility RN schedule from July 2025 to December 2025 revealed that the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day for the 6-month review period for the following dates: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025.
Staff interview on 1/7/2026 at 2:09 p.m. with the Administrator, she stated the previous DON had to be released from employment, and during the hiring process, there were no RN applicants due to the location and population making it difficult to attract a sufficient number of qualified candidates.
She stated that if RNs did not work at the facility, it could lead to improper care for residents.
Record review of the facility policy, titled Staffing, Sufficient, and Competent Nursing, revised 08/2022, revealed 3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.
Registered nurses may be scheduled more than eight (8) hours depending on the acuity needs of the 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
676288 01/08/2026
Avir at Cotulla 369 Mars Dr Cotulla, TX 78014
During an interview with LVN A on 1/07/2026 at 3:06 PM, LVN A stated it was important to count the controlled medications for inventory accuracy and document on the controlled medication reconciliation log to make sure the count is correct when taking supervision of a medication cart. LVN A stated if they did not count and document the counting of the controlled medications, a pill could be missing, and they would not know when the loss occurred. LVN A stated if a resident was missing a pill, they might not get the benefit of their medication.
During an interview with the DON on 01/07/2026 at 4:24 PM, the DON stated staff responsible for medication carts had never counted the controlled medications when handing off their key to another staff member before lunch.
The DON stated moving forward, her expectation was for staff to count and document the count of controlled medications when they hand off their key to another staff member before lunch or anytime they relinquish their key.
The DON stated if staff did not reconcile the controlled medications in their carts before handing over their key to another staff member, something could go missing and they would not know where or when a medication was lost.
During an interview with LVN B on 01/08/2026 at 8:10 AM, LVN B stated when they hand over their medication cart key to another staff member before lunch it was important that they count and document the controlled medications in their cart, because medications could go missing. LVN B stated moving forward, they will sign the new log developed for documenting the count of controlled substance when handing off their key to another staff member before lunch.
Record review of the facility policy titled Controlled Substances with a revision date of November 2022, noted Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection/follow-up.
The policy further stated, The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.
676288 01/08/2026
Avir at Cotulla 369 Mars Dr Cotulla, TX 78014
During an interview on 01/06/2026 at 10:16 a.m., the Dietary manager stated food temperatures should be taken as soon as food items were put on the steam table, for every meal, and every day.
The dietary manager stated the cook and dietary manager were responsible for dating products as they got food deliveries.
The dietary manager stated the risk to the residents for not dating food products or taking temperatures of food could be food items building bacteria and risk of expiration.
The Dietary manager stated they were not aware of any food borne illness outbreaks within the facility.
During an interview on 01/07/2026 at 10:48 a.m., the DON stated they were not aware of any food borne illness outbreaks since being employed at the facility.
During an interview on 01/08/2026 at 11:47 a.m., the [NAME] stated they were supposed to take the temperature of all foods before every meal.
The [NAME] stated the purpose was to check to see if the temperature is appropriate to serve to residents.
The [NAME] stated they would have to get back with what the risk could be to residents if they are not checking the food temperatures of food items.
Record review of the facility's policy, Food Storage, dated 2023, reflected: 8.
All containers or storage bags must be legible and accurately labeled and dated.
Record review of the facility's policy, Food Temperatures, dated 2023, reflected: The temperatures of all food items will be taken and properly recorded prior to service of each meal
676288 01/08/2026
Avir at Cotulla 369 Mars Dr Cotulla, TX 78014
During an interview on 01/06/2026 at 10:44 a.m. the resident in room [ROOM NUMBER]-A stated staff had not been labeling their food items located in their personal fridges, but that staff had been checking for the fridge's temperature.
The resident in room [ROOM NUMBER]-A stated the food items were brought in by himself and family.
Observation on 01/07/2026, at 7:53 a.m. revealed that the personal refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard, which had been previously opened, with expiration dates hard to obtain, which were unlabeled and undated.
During an interview on 01/07/2026, at 10:33 a.m., CNA C stated housekeeping usually checks resident's fridges, but those items should be labeled and dated. CNA C confirmed that the refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard which were unlabeled and undated. CNA C stated if items in residents' fridges are not labeled staff would not know whose items were whose.
During an interview on 01/07/2026, at 10:39 a.m., LVN D stated nurses and CNAs were responsible for checking residents' personal fridges nightly for at least expirations dates and if the item is open then staff should date the item. LVN D stated staff check the fridges for their temperature as well. LVN D stated items should be dated in residents' personal fridges. LVN D confirmed that the refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard which were unlabeled and undated. LVN D stated if items in residents' fridges are not labeled there could be a risk for residents to get sick if the item is expired.
During an interview on 01/07/2026, at 10:48 a.m., the DON stated the housekeeping checks residents' personal fridges for temperatures and in case anything needs to be thrown away.
The DON stated staff would not know whose items were whose in residents' fridges if they were not labeled.
The DON stated if items in residents' fridges are not labeled there could be a risk for residents to have an upset stomach if they were unsure how long the item had been opened.
During an interview on 01/07/2026, at 11:06 a.m., HSKP stated they check residents' personal fridges for temperatures but was unsure if they were supposed to be checking for labels or dates. HSKP stated if an item in a resident's personal fridge has been out for a while and there weren't sure if the item was still good, they would just throw it out.
Record review of the facility policy, Food Brought in by Family/Visitors, revised March 2022, revealed,Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food.Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator.
Containers are labeled with the resident's name, the item and the use by date.
676288 01/08/2026
Avir at Cotulla 369 Mars Dr Cotulla, TX 78014
The facility failed to ensure LVN B wore a PPE gown while administering medication to Resident #6 via PEG tube (a flexible feeding tube inserted through the abdominal wall into the stomach that allows for the delivery of nutrition, fluids, and medications directly into the stomach).
This failure could place residents at risk for cross contamination and infection.The findings included:
Record review of Resident #6's admission sheet dated 6/30/2025 with an original admission date of 4/15/2013 documented a [AGE] year-old female resident with diagnoses including multiple sclerosis (a disease that causes breakdown of the protective covering of nerves causing numbness, weakness, trouble walking, and vision changes), dementia, peripheral vascular disease (when arteries in the limbs are narrowed, limiting blood flow), depression, and epilepsy (seizure disorder).
Record review of Resident #6's quarterly MDS assessment dated [DATE] documented a BIMS could not be conducted due to the resident rarely or never being understood and recorded the use of a feeding tube in Section K - Swallowing/Nutritional Status K0520 Nutritional Approaches.
Record review of Resident #6's order summary documented an active order for ENHANCED BARRIER PRECAUTIONS G Tube with an order date of 11/30/2025 and no end date.
Record review of Resident #6's care plan with an initiation date of 6/06/2024 documented the resident required Enhanced Barrier Precautions r/t use of my G tube for all my nutritional, hydration, and medication needs. with interventions including Follow Facility policy.
During an observation of g-tube medication administration on 01/08/2026 at 7:05 AM, LVN B was observed wearing gloves while administering medications through Resident #6's g-tube. LVN B did not wear a protective gown while administering the medications. A sign regarding information for EBP was observed posted on Resident #6's door.
During an interview with LVN B on 01/08/2026 at 8:10 AM, LVN B stated Resident #6 did not have a specific order to wear a gown, and that she only wore gloves when she administered medications through the resident's g-tube. LVN B stated it was important to wear EBP to protect both staff and residents from contamination during care.
During an interview with the DON on 01/08/2026 at 9:08 AM, the DON stated her understanding regarding EBP was that it was important because you do not want to spread infection between staff and residents.
The DON stated her expectation was for staff to wear gowns and gloves any time they provided care which indicated the use of EBP.
The DON stated she had already begun instructing her staff on proper EBP usage.
During an interview with the ADON on 01/08/2026 at 9:55 AM, the ADON stated she had been the facility IP since 2022.
The ADON stated her expectation was that staff should be wearing EBP during care, whenever a resident is under isolation, or any time it is indicated including care provided with a g-tube.
The ADON stated with any use of the g-tube she expected her staff to wear gowns and gloves, and that the wearing of these items was important to prevent transmission of infections between staff and residents.
The ADON stated she had been working with the DON to reeducate staff on proper EBP procedures.
Review of facility policy Enhanced Barrier Precautions with a revision date of February 2025 noted Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. and Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.