Avir At Kennedale
Avir at Kennedale in Kennedale, TX — inspection on September 3, 2025.
Found 14 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
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0553 during a standard health inspection conducted on 2025-09-03.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0565 during a standard health inspection conducted on 2025-09-03.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0607 during a standard health inspection conducted on 2025-09-03.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0609 during a standard health inspection conducted on 2025-09-03.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
stated the following day she followed-up with the family, and the family informed her the other facility was a better fit for the resident.
The Administrator stated she was upset at how Resident #24's transfer was not handled appropriately by the DON.
She stated it was a lack of communication.
She stated the potential risk would be the family not knowing where the resident had transferred.
Interview on 09/03/25 at 3:42 PM with Resident #24's POA revealed she was informed by a family member of Resident #24's discharge.
The POA stated prior to Resident #24 discharging she only received a voicemail on Friday 08/08/25 regarding the resident's elopement with consideration to possibly moving the resident to a secure unit.
She stated no agreement was made for Resident #24 to be discharged from the facility.
Interview on 09/03/25 at 6:08 PM with the MD revealed he was made aware of Resident #24's discharge. He stated Resident #24 eloped from the facility and was at high risk for elopement.
The MD stated he approved the resident's transfer to another facility. He stated he expected for the facility to notify the family of the transfer prior to the resident discharging.
Record review of the facility's Discharge - Transfer of the Resident, dated 12/2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Kennedale
413 E Mansfield Cardinal Kennedale, TX 76060
SUMMARY STATEMENT OF DEFICIENCIES
responsible for completing discharge summaries.
She stated if the discharge nurse was unable to complete the discharge summary, the nurse should notify her, and she would complete it.
The DON stated due to the change of system they were behind on things, and Resident #24's discharge summary was one of the things that needed to be completed.
She stated it was her responsibility to ensure discharge summaries were completed.
Record review of the facility's Discharge - Transfer of the Resident policy, dated December 2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software.9.
Discharge Summary completed by DON/designee.
Facility ID:
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-09-03.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level K: pattern, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Past Non-Compliance.
The facility reported correction as of 2025-08-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-09-03.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-09-03.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Past Non-Compliance.
The facility reported correction as of 2025-08-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-09-03.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-09-03.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-03.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0803 during a standard health inspection conducted on 2025-09-03.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.
Federal health inspectors cited Avir at Kennedale in Kennedale, TX for a deficiency under regulatory tag F-F0805 during a standard health inspection conducted on 2025-09-03.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Avir at Kennedale.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-04.