Avir At Kerrville

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #1 pushed his call light, when staff responded he requested repositioning, three therapy staff and 1 CNA responded to reposition the resident. During an interview on 10/01/2025 at 4:00 p.m., LVN A stated Resident #1 utilized his call light a lot and required staff assistance and attention frequently. LVN A stated Resident #1 was on Ozempic (Semaglutide) and they were trying to get him to lose weight so he would be healthier and could participate in his own care and in therapy. LVN A stated the resident could have snacks

in addition to his prescribed diet. He stated staff should monitor his food intake and record it in the medical record. LVN A stated he did not have anything to do with the care plans and was not certain what should be contained in them. He stated he wasn't sure who was responsible for the care plans. During an interview on 10/01/2025 at 5:05 p.m., the MDS Coordinator stated Resident #1 was totally dependent on staff for his care and needed help with moving, sitting, etc[TF5] . She stated Resident #1's care plan did not specify what his bed mobility or other ADL requirements were, or the number of staff needed to provide his care.

She stated a place holder was added to the care plan, but the care itself was not specified. The MDS Coordinator stated Resident #1's care plan also included spaces for cardiac diet with no interventions because that part of the care plan was not finished. She stated the part that indicated intake more than body requirements was created but an evaluation of the resident's weight and goals were not specified. The MDS Coordinator stated she was the only full-time MDS Coordinator at the facility. She stated care plans were primarily her responsibility. She stated they used to have weekly care plan meetings on Thursdays, and they had not occurred in one month. She stated she was new to the role of MDS Coordinator and needed more assistance. She stated complete care plans were important so the facility could meet the resident's level of care and because it was used as a reference for how nurses cared for the resident[TF6] .

During an interview on 10/01/2025 at 5:32 p.m., the ADON stated the care plans were completed by the RN's and the MDS Coordinator. She stated the DON reviewed and signed them. She stated she could make suggestions for the care plans but did not edit them because she was an LVN. During an interview on 10/01/2025 at 6:00 p.m., the DON stated the facility ran into a glitch with care plans. She stated when a LVN completed an assessment it opened up a baseline care plan in the medical record. She stated she had to go into the record, delete them and reopen a care plan. She stated the computer software company was working on a solution. The DON stated the MDS Coordinator was responsible for ensuring the comprehensive care plans were complete, but again because of the glitch they were not triggering, and it was a known problem. The DON stated an accurate care plan was important, so they knew how to care for

the resident. Record review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. the comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, c. includes the resident's stated goals upon admission and desired outcomes d. builds on the resident's strengths and e. reflects currently recognized standards of practice for problem areas and conditions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Kerrville

1555 Bandera Hwy Kerrville, TX 78028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0680

Ensure the activities program is directed by a qualified professional.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State to for 72 of 72 residents reviewed for qualifications of activity professionals.The facility failed to have a qualified Activities Professional to direct their activities program.This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.The findings include: During an interview on 10/01/2025 at 3:40 p.m., the HR [TF1] Director stated the personnel file for the Activity Director did not have any proof of education. He stated it was his understanding, the Activity Director had a year to complete training. The HR Director stated the Administrator had intentions on enrolling the Activity Director in training but as of this interview she had not yet been enrolled. During an interview on 10/01/2025 at 4:46 p.m., the Activity Director stated she was the facility Activity Coordinator. She stated she had been in the position for the past 4-5 weeks. She stated she did not have any training right now and was not currently enrolled in any training for Activity Director. She stated she was not an OT[TF2] or OTA[TF3] , and she did not have any prior experience. She stated she was doing a little trial run to see if she was interested in the position. She stated she wanted to make sure

she could take the job seriously and do the position justice and do it right. The Activity Director stated she loved the job. She stated she communicated to the Administrator within the first week that she wanted to do

it full time. During an interview on 10/02/2025 at 1:03 p.m., the Administrator stated the Activity Director was hired as an assistant because she worked at as CNA. The Administrator stated the facility was working

on getting her certified and she was going to be enrolled in one of the training courses for Activity Director.

He stated she was not currently registered for the training. The Administrator stated he did not have anyone else who met the Activity Director requirements. He stated it was important to have an Activity Director on staff who met requirements to assist with cognition, so residents' had the opportunity to express themselves and so they could flourish in their home[TF4] [TF5] . Record review of the facility's, unsigned and undated, job description for the Activity Coordinator, revealed: Qualifications: previous office experience preferred, previous nursing home experience preferred, previous supervisory experience preferred. Record

review of the facility's policy titled Activity Program, dated June 2018, revealed: The Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. The policy did not address the Activity Director.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Kerrville

1555 Bandera Hwy Kerrville, TX 78028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

no that was not okay. She stated she told RN B it was never okay to document under someone else. The DON stated it was falsifying documentation and could get someone in trouble. The DON stated LVN A was not graining [TF3] RN B on any nursing skills. He was training her on the computer. She stated she told HR

she did not want RN B back in the building after this occurred. Record review of the facility's policy titled Charting and Documentation, dated July 2017, revealed: 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g. RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy.

Event ID:

Facility ID:

If continuation sheet