Avir At Western Hills
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
are some residents who were allowed to go to the convenience store. When she was leaving, the SW was coming out of the facility and came to get Resident #1 and took him back to the facility. In an interview on 11/19/2025 at 12:30 PM with the ADM, the ADM stated there was no specific policy/procedure for what to do when the alarm goes off. They had a policy if a resident leaves the building, the ADM stated a resident with a code system alert bracelet who went outside without supervision could get injured.In an interview on 11/20/2025 at 9:50 AM with the CMA. The CMA stated if she hears the door alarm go off, she will go to the nurses' station to look at the control box and find out which door was opened. Then she will check the room of the resident with a code alert bracelet on. The CMA knows which residents have a code alert bracelet on because there were only two in the facility. The CMA will then go find the resident. The CMA stated when
she sees a resident with a code alert bracelet going to the door, she will redirect them. The CMA said if a resident with a code alert bracelet makes it outside, they could be hit by a car, fall and get injured, or tip out of the wheelchair. The CMA stated she was in-serviced on elopements last week.In an interview on 11/20/2025 at 10:30 AM with the LVN, the LVN said when the alarm goes off, she will try to find the resident. The LVN said that when a resident with a code-alert bracelet gets close to the door, the door alarm goes off and should lock. When they cross the barrier, the alarm goes off. The LVN said they check
the control box at the nurses' station to see what door was open, then she will go find the resident. LVN said that she works with Residnet #1 and if she sees him going to to the door she will redirect him. The resident was then assessed for injuries. The ADM was made aware of the incident. She said that she has been in-service on elopement and what she is supposed to do if a resident elopes from the facilityRecord reviewResident Monitoring System log for residents with the wandering system revealed the test done on 11-10-2025, which showed the door was working. The test was completed weekly and daily since the elopement on 11-12-2025, after Resident #1 left the facility, showing that the door was not working. The facility took the following PNC Corrective actions before the surveyor's entrance: The facility was repaired
on 11-13-2025 by [NAME] Fire and Safety before the investigation. The facility had in-service training on elopement with all staff in the facility and the training was signed by all staff prior to the investigation being done on 11/19/2024 MD has been checking the door daily since the incident took place on 11/12/2025 to make sure the door is working and that residents with. The facility policy on Wandering and Elopements is as follows. The policy does not have a date when it was updated. The resident with a risk of wandering will be identified in the care plan with strategies and interventions. If an employee should prevent them from leaving, they and get help if needed.
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If continuation sheet
Avir at Western Hills in Temple, 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 Temple, 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 Western Hills or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.