Avir At Lancaster
Inspection Findings
F-Tag F0567
F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
out and signed the log. It was then passed to the person receiving the cash and the log was signed by that person. She stated the BOM did not have a witness or that second person observe the transaction. She stated during a corporate audit the issue with the BOM not having a witness when she dispensed cash was found. She stated corporate called and asked for the Resident Trust Fund Petty Cash Log report that she was not aware she needed to submit, at that point they conducted an audit. She stated that corporate was conducting the investigation, so she was not fully aware of all details at this time. She stated she did not believe there were any funds missing, it was a process that was not being followed. A telephone interview was attempted with the facility BOM on 09/30/2025 at 3:01 pm and 3:45pm. without success. A message was left on the telephone and requested a call back. (No call was received prior to exit.)An interview with corporate BOM on 09/30/2025 at 3:07 pm, revealed during an audit it was found that the business office manager was not following proper procedures. She stated her manager(regional BOM) would be able to give greater detail about the situation and provided a number for her.An interview with Regional Business Office Manager on 09/30/2025 03:26 pm she stated they found an issue where the BOM was not having a witness and witness signature when the BOM passed out funds. Corporate audited several resident's records and Resident #5 was the only one they had questions about. She stated some transactions had witnesses and other's only had the business office manager's signature. When corporate staff talked to Resident #5 she reported she never got more than $50 At that point the corporate office was not sure if Resident #5 was being sincere or deceitful. The corporate office decided for every transaction over $50 they would reimburse the resident the difference and came up with $310. During the corporate investigation they were provided receipt from a clothing purchase for almost $200 (provided by Resident #5 for the same time period.). Regional BOM stated they still covered the $150. Corporate staff confirmed they do not believe that BOM took any money, she was just not following the proper policy for disbursement of funds and the police were notified. The corporate office reconciled the funds and found no discrepancies other than the procedure was not followed. The Regional BOM stated they understood that the resident does have cognitive issues and may not remember the exact amounts, but the corporation did not want to appear like
they were hiding anything, So the $310 was the amount we thought was most accurate. There was a corporate training class at the end of August 2025, for all of the business office managers and the facility BOM was present. Effective September 1, 2025, the facility BOM should have been followed the policy from that point on. (No evidence of training was provided.)An interview with the administrator on 10/17/2025 at 12:05 pm revealed the BOM had not returned to the building since 09/22/2025 when she was suspended and was terminated effective 10/10/2025. She stated that after the initial findings she decided to terminate
the BOM. She stated the BOM was scheduled to come in on 10/08/2025 for a meeting but never showed up. The termination papers were signed on 10/10/2025. Review of punch detail for BOM dated September 2025 reflected BOM's last day worked was on 09/22/2025.
Event ID:
Facility ID:
If continuation sheet
Avir at Lancaster in Lancaster, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.