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Complaint Investigation

Avir At Lancaster

Inspection Date: November 5, 2025
Total Violations 1
Facility ID 675809
Location Lancaster, TX
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Inspection Findings

F-Tag F0568

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and facility policy review, the facility failed to ensure the individual financial record must be available to the resident through quarterly statements and upon request for 1 (Resident #1) of 5 residents reviewed for personal funds. The facility failed to provide statements of personal funds upon request. This failure could place the residents at risk of not having knowledge of the balance of their funds. Findings included:Record Review of Resident #1 face sheet, dated 11/0525, revealed a [AGE] year-old man originally admitted on [DATE REDACTED] with a diagnosis of end stage renal disease (kidneys have severely damaged and can no longer function properly), anxiety disorder due to known physiological condition (mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life). Record

review of Resident #1's discharge MDS assessment, dated 09/26/2025, revealed Resident #1 BIMS score of 14 which indicated intact cognitive function. Record review of an undated list of residents provided by the ADM revealed that 26 residents received healthcare insurance funds. The list included Resident #1. An

interview on 11/05/25 at 11:16 a.m., the BOM revealed she was hired on 10/27/25 and on 10/29/25 Resident #1 asked for her to provide a printout of his account statements. The BOM stated Resident #1 revealed to her that he had not received a statement since July 2025. The BOM could not provide evidence that Resident 1's received monthly statements from July to September that he had requested. The BOM stated residents who had a trust fund must be provided with a monthly statement and a quarterly trust fund statement. The BOM stated that the importance of the statement was to inform the residents where he or

she money went and how much remained. An interview on 11/05/25 at 12:47 p.m., Resident #1 revealed that he had not been provided with an account statement since July until the current BOM gave him one on 10/29/25. Resident #1 stated that he would like to see how much remained on his account to ensure he didn't overdraw his account. Resident #1 stated that the BOM provided his balance, but he wanted preferred the statement. An interview on 11/05/25 at 4:17 p.m., with the ADM revealed he was hired on 10/27/25 and upon hire he ensured the new BOM provided all residents with their most recent October statement. The ADM stated that his expectation was for the facility to provide them with the monthly schedule and as requested by the residents, it is their right to know how their funds are being used.Requested resident rights policy from BOM on 11/05/25 did not receive prior to exit.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

Avir at Lancaster in Lancaster, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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