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Complaint Investigation

Avir At Kerrville

April 24, 2026 · Kerrville, TX · 1555 Bandera Hwy
Citations 7
CMS Rating 1/5
Beds 130
Provider ID 745050
Healthcare Facility
Avir At Kerrville
Kerrville, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Avir at Kerrville in Kerrville, TX — inspection on April 24, 2026.

Found 7 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

FF0567
Resident Rights Deficiencies

Review of facility policy, Resident Rights, dated February 2021, read in relevant part,1.

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

These rights include the resident's rights to:e. self-determination; h. be supported by the facility in exercising his or her rights; r. manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes).

745050 04/24/2026

Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

Investigation Report 3613-A to Texas HHSC within 5 days, and he said the facility administrator should have conducted thorough investigation regarding Resident #2's allegation and submitted provider investigation report 3613-A to Texas HHSC within 5 days to prevent possible abuse or neglect.

Record review of the facility policy, titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 09/2022, revealed . 7.

All allegations are thoroughly investigated.

The administrator initiates investigations.

Follow-Up Report. 1.

Within five (5) days of the incident, the administrator will provide a follow-up investigation report. 2.

The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified.

745050 04/24/2026

Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

Appropriate care and services will be provided for residents who are unable to carry out ADL's

745050 04/24/2026

Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

prevent accidents.

the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving

environment. A lunch tray that had leftover food without a cover was on the furniture unattended at the 400-hallway.

This failure could place residents at risk for foodborne illness or choking if some confused residents might eat the leftover food on the lunch tray.

The findings include: Observation on 04/21/2026 at 3:40 p.m. revealed one lunch tray was on the furniture at the middle of 400-hallway unattended, the lunch tray had leftover food that some resident in 400-hall ate and left, and the main lunch dish was very open without a cover.

Further observation revealed nobody was on the 400-hallway, and the leftover food was cornbread, squash, salad, and chocolate chip cookies.

Further observation revealed no residents wandered on the 400-hallway.

Interview on 04/21/2026 at 3:41 p.m., the ADON stated one lunch tray that had leftover food some resident in 400-hall ate and left was on the furniture unattended at the 400-hallway, and the lunch dish was very open without a cover.

The ADON said open lunch tray without a cover unattended was not good because some confused residents who had different food textures might eat the leftover food on the tray and might have choking.

The ADON said staff should have returned all lunch trays to the kitchen, instead of putting the tray on the furniture on the 400-hallway.

Interview on 04/21/2026 at 3:45 p.m. with DON said it was not acceptable that staff put lunch trays with leftover food on the furniture at the 400-hallway unattended because some confused residents might eat the leftover food and might have infection or choking, and staff should have returned all lunch trays to the kitchen immediately whenever residents completed eating their lunch in their rooms and said the facility did not have a policy related to meal trays, but the facility should maintain safe environment for residents.

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Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

might not try to take the med from emergency kit, contact physician, pharmacy, or even DON or

not receive the medication, the resident might have anxiety, but per the resident's medical record, the

facility.

Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 8. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the mediation will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

745050 04/24/2026

Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

Based on observations, interviews, and record review, the facility failed to ensure all drugs and

locked compartments for 1 (400-hall nursing cart) of 3 medication carts reviewed for medication storage.

The facility failed to ensure the 400-hall nursing cart was not left unlocked and unattended on 04/23/2026.

These failures could place residents at risk of ingesting medications not prescribed for them or drug diversion.

The findings were:Observation on 04/23/2026 at 9:12 a.m., revealed the 400-hall nursing cart was unlocked and unattended.

Interview on 04/23/2026 at 9:18 a.m., LVN-C stated the 400-hall nursing cart was unlocked and unattended. LVN C said she forgot to lock the cart when she left to see some residents, she said it was her mistake.

The nurse stated nursing carts should be locked at all times to prevent someone from taking any medication.

Interview on 04/23/2026 at 5:15 p.m., the DON said facility nurses should always lock the medication carts to prevent someone from taking the medications.

Record review of the facility policy, titled Administering Medications, revised 04/2019, revealed . 19.

During administering of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept top of the cart.

The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

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Avir at Kerrville 1555 Bandera Hwy Kerrville, TX 78028

Findings included: 1.

Observation of the kitchen on 04/23/2026 at 10:05 a.m., revealed there was one packet of hamburger burns (total 15 burns inside the packet) on the cooking table, the label on the packet said, Best used by 04/22/2026. 2.

Observation on 04/23/2026 at 10:10 a.m., revealed a refrigerator labeled as C-1 Refrigerator had a tray with Jello inside, the Jello was not labeled and dated.

Interview on 04/23/2026 at 10:13 a.m., the kitchen manager stated the hamburger buns expired on 04/22/2026, so the facility kitchen staff should have discarded it to prevent possible use and food-borne illness.

Further interview with the kitchen manager said the facility staff should have labeled and dated the Jello located inside C-1 refrigerator per the facility policy and to prevent possible food-borne illness, and it was kitchen manager's responsibility to discard expired food.

Record review of the facility policy, titled Food Receiving and Storage, revised 11/2022, revealed 1.

All foods stored in the refrigerator or freezer are covered, labeled and dated ( used by date). 7.

Refrigerator foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

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 Kerrville, 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 Kerrville or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

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.