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Complaint Investigation

Avir At Veterans Memorial

October 31, 2025 · Houston, TX · 1424 Fallbrook Drive
Citations 3
CMS Rating 3/5
Beds 120
Provider ID 676252
Healthcare Facility
Avir At Veterans Memorial
Houston, TX  ·  View full profile →
Inspection Summary

Avir at Veterans Memorial in Houston, TX — inspection on October 31, 2025.

Found 3 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.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

right to feel like they are humans, and it was the responsibility of all staff to make sure that resident rights were protected. He said he would report to the Administrator if a resident's rights were not respected. He said a negative effect of not respecting resident rights might be that residents were affected emotionally. He said residents have the same rights as any other person.Interview on 10/31/25 at 11:02 am with LVN F reflected he worked with CNA G, and he felt like she was respectful to residents and no residents complained about the way she treated them. He said he was trained in resident rights when he was hired at the facility, and it was the responsibility of everyone to protect resident rights. He said examples of resident rights were the right to privacy, to be treated fairly and respectfully and to make decisions of their own choices. If a staff member did not allow a resident to ask questions that would be inconsiderate and disrespectful and was a violation of resident rights and borderline abusive. LVN F said if he felt a resident's rights were being disrespected, he would talk to the staff member who was not respecting the resident's rights then speak to the resident then let the ADON or DON know.

Allegations of abuse and neglect were reported to the Administrator first and foremost and he would also report resident rights issues to the Administrator.Interview on 10/31/25 at 11:13 am with the DON reflected resident rights involved honoring residents' likes and dislikes and respecting and honoring residents' wishes.

The DON said this included making sure Residents' feelings were not hurt and they were respected.

She said residents have the right to know they have a say and for their voice to be heard.

She said that after the SSA brought the Life Satisfaction results involving CNA G to her attention and the Administrator, they talked with the residents and let them know CNA G would not be back.

She said it was the responsibility of everyone to protect the residents' rights, from the nurses to the CNAs to the dietary staff, everyone.

Interview on 10/31/25 at 11:11 am with the Administrator reflected after the life satisfaction surveys were reported to her, she would have terminated CNA G's employment, but CNA G already resigned.

She said, after hearing what Residents #4, #5, #6, and #7 felt about how CNA G made them feel, it was possible she violated their rights.

She said the staff were trained in resident rights when they were hired and it was the responsibility of everyone to make sure residents had their rights protected. It was her expectation that staff reported to her any knowledge of resident rights violation.

She said the possible negative effect of resident's having their resident rights violated would be residents could regress and not feel they have rights in their living space.

Review of facility Resident Right's Policy dated February 2021 reflected employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1.

Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the residents' right to: 1. a dignified existence;2. be treated with respect, kindness, and dignity;3. be free from abuse, neglect, misappropriation of property 4. communication with and access to people and services, both inside and outside the facility;exercise his or her rights as a resident

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Capstone Healthcare Estates at Veterans Memorial

1424 Fallbrook Drive Houston, TX 77038

SUMMARY STATEMENT OF DEFICIENCIES

During interviews on 10/29/25 from 2:27 pm - 10/31/25 at 10:25 am, four LVNs, 1 LPN, and 10 CNAs from different shifts all stated they were in-serviced by the ADON and DON on 1. facility Abuse and Neglect Policy and Procedures2. always operate mechanical lift with 2 (two) staff members and staff should verify mechanical lift is fully functional and operating properly. If the mechanical lift is not functioning properly staff are to pull it off the floor, notify management/maintenance director and put a work order in TELS (a service request platform used by facilities for maintenance and operations).3. to check gait belts and slings daily every shift for any tears, holes, or thread unraveling. If any defects are noted to equipment staff are to pull it from the floor and notify DON/ADON immediately.

Shower (mesh) slings are only to be used for residents when giving showers.

They are not to be used for everyday get up to participate in daily activities.

Staff to ensure batteries sufficiently charged before each use of mechanical lift/sit to stand before use to ensure they are functioning properly.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Capstone Healthcare Estates at Veterans Memorial

1424 Fallbrook Drive Houston, TX 77038

SUMMARY STATEMENT OF DEFICIENCIES

that the staff initiated and followed the PICC line dressing changes after his return from the hospital with another PICC line, on 07/21/25.

Record review of the in-service file revealed on 07/16/25 the facility conducted an in service on IV care and Monitoring.

The staff were educated on the following1. IVs are to be flushed Q shift as well as before and after med administration2. IV site to be cleaned and dressing changed Q Sunday and PRN3. IV site to be monitored Q shift and PRN for patency , infiltration, phlebitis [bleeding] and infection.4.

Any and all change in condition to be reported to nurse management immediately and documentation completed .

Record review of facility policy Midline Dressing Changes revised in April 2016 reflected: The purpose of this procedure is to prevent catheter related infections associated with contaminated , loosened or soiled catheter site dressings.1.

Change midline catheter dressing 24hours after catheter insertion and every 5-7days , or if it is wet, dirty, not intact or compromised in any way .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Houston, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Veterans Memorial or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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