Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Kennedale during CMS and state inspections, most recent first.
The facility did not maintain required RN coverage for at least eight consecutive hours daily, as shown by staffing records indicating multiple weekend days without any RN on duty during a two‑month review period. The facility’s own staffing policy required an RN to provide services eight hours every 24 hours, seven days a week, but this was not met. In interviews, the ADON, DON, and Administrator acknowledged ongoing difficulty hiring and retaining a weekend RN, confirmed that the facility had been without weekend RN coverage for an extended period, and recognized that an RN is needed for tasks outside LVN scope and for appropriate oversight.
A resident with multiple chronic conditions and dysphagia received ordered bolus g-tube feedings of Glucerna 1.5, but an LVN prepared a feeding by adding an unknown amount of tap water to the formula before administration, contrary to the physician’s written orders and facility policy. The LVN reported diluting the formula so it would flow more quickly and believed this was permitted, while the ADON and DON both stated that g-tube formula should not be diluted without a specific physician order and that enteral nutrition is to be provided exactly as ordered.
A resident with multiple chronic conditions and a g-tube for dysphagia received several ordered oral medications (including apixaban, atorvastatin, acetaminophen-codeine, and calcium carbonate-vitamin D) via g-tube in a manner that did not follow facility policy. An LVN routinely crushed and mixed all of the resident’s medications together in one cup, added a large volume of water, and administered the combined mixture through the g-tube, rather than preparing and giving each medication separately with appropriate water flushes between them. The ADON and DON reported they were unaware this practice was occurring and confirmed that it was inconsistent with the facility’s written enteral medication administration policy, which requires separate preparation and administration of each medication unless there is a specific physician order to mix them.
A resident with hemiplegia, non-Alzheimer’s dementia, aphasia, moderate cognitive impairment, and total dependence for care was observed receiving incontinence care and a shower from a CNA who failed to follow infection control practices. The CNA continued perineal care, applied a clean brief, handled a Hoyer sling and lift, transferred the resident, and provided a shower while wearing gloves visibly soiled with fecal matter, without performing hand hygiene or changing gloves. The CNA only removed gloves after the shower and then dried the resident without hand hygiene. Staff interviews and facility policies confirmed that hand hygiene and glove changes were required when gloves are soiled, when moving from dirty to clean tasks, and when entering or exiting rooms, and that not doing so could cause infection, cross-contamination, spread of germs, or fungal issues.
A resident with a history of stroke, pressure ulcers, and mobility-related skin concerns had a physician order for Mupirocin 2% ointment to be applied to the left great toe twice daily after cleansing and covering with a dry dressing, but the Treatment Administration Record showed missing documentation of twice-daily wound care on multiple days, and observations found the toe dressing unchanged over several hours. The treatment nurse and an LVN both believed or acted as though the wound care was ordered once daily, and the LVN acknowledged not providing the wound care that day, while the regional nurse consultant stated staff follow physician orders and noted the risk of not following them. The facility’s wound care policy required verification of physician orders and documentation of the date and initials of the person performing wound care.
A resident with multiple wounds and moderate cognitive impairment did not receive or have documented wound care on several occasions as ordered by the physician. Nursing staff failed to document the provision of wound care or any refusals, and facility leadership was unaware of the missed care. This resulted in a failure to ensure necessary treatment and services were provided according to professional standards.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on nine occasions. This was due to RNs, including the DON, working shifts that did not meet the required duration, often because of breaks. The DON was unaware of the non-compliance, and the facility lacked a specific policy for RN coverage, relying instead on CMS guidelines.
A resident receiving IV Meropenem for sepsis and bacteremia was administered medication by an LVN who failed to label the IV bag and tubing with the date, time, and her initials, as required by facility policy. The LVN acknowledged the oversight, which could lead to medication errors and infection control issues. The DON confirmed the labeling requirement, but no adverse events had occurred yet.
The facility failed to accurately report licensed nurse hours to CMS for eight days in FY Quarter 1 2024, despite having 24-hour coverage according to staff timesheets. The issue was due to a system error in pulling LVN worked hours, which the Corporate Analyst identified and corrected. The Administrator was unaware of the reporting details, and the facility lacked a specific PBJ staffing policy.
Failure to Maintain Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulation and by its own policy. Review of the facility’s Detailed Hours report for the period from 02/07/26 to 04/05/26 showed there was no RN coverage on multiple weekend dates: 02/08/26, 02/14/26, 02/15/26, 02/21/26, 02/22/26, 02/29/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/22/26, 03/28/26, and 03/29/26. The facility’s written policy on Staffing, Sufficient, and Competent Nursing, revised August 2022, stated that an RN would provide services at least eight hours every 24 hours, seven days a week, but this was not followed on the identified dates. During interviews, the ADON stated the facility had been having difficulty finding and retaining an RN for weekend coverage and acknowledged they had been without one for “quite a while.” The ADON also stated an RN should be present on weekends in case something occurred that was outside the scope of practice of an LVN. The newly hired DON, who had been at the facility for three days, reported being told that the facility had recently lost its weekend RN and was not aware there were so many days without RN coverage, and affirmed that having an RN for eight consecutive hours Monday through Sunday was important because it was a state regulation. The Administrator similarly reported that the facility had not had a weekend RN for quite some time and acknowledged the importance of having an RN seven days a week for eight hours for tasks outside LVN scope and for better oversight.
Unauthorized Dilution of Enteral Formula Prior to G-Tube Administration
Penalty
Summary
The deficiency involved a failure to ensure that a resident receiving enteral nutrition via a g-tube received treatment and services in accordance with physician orders and facility policy. The resident was an older female with multiple diagnoses including hypertension, hyperlipidemia, respiratory failure, diabetes, end stage renal disease, and pain, with moderately impaired cognition and a care plan indicating the need for tube feeding related to dysphagia. Her physician orders specified bolus enteral feedings of Glucerna 1.5, with defined volumes and times. During an observation, LVN C prepared the resident’s g-tube feeding by pouring an undisclosed amount of tap water into cups containing the ordered formula before administering it through the g-tube, then flushing with water afterward. In a subsequent interview, LVN C stated she added water to the formula to dilute it so it would not take a long time to go down the tube and acknowledged she did not recall how much water she used. She reported believing she had been told by the ADON that she could dilute the formula, but the ADON later stated she was not aware LVN C was diluting the formula and denied instructing her to do so, clarifying that dilution could only occur with a physician’s order. The DON also stated the resident’s formula should not have been diluted without a physician’s order and that doing so could affect the concentration of the formula or cause overload and put the resident at risk of aspiration. The facility’s Enteral Nutrition policy indicated that enteral nutrition would be provided as ordered by the physician based on dietitian recommendations, which was not followed in this instance.
Improper Mixing and Administration of G-Tube Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications via a g-tube in accordance with facility policy for one resident. The resident was an adult female with multiple diagnoses including hypertension, hyperlipidemia, respiratory failure, diabetes, end stage renal disease, and pain, and had a g-tube for tube feeding related to dysphagia. Her physician’s orders included several oral tablets (apixaban, atorvastatin, acetaminophen-codeine, and calcium carbonate-vitamin D with minerals) to be administered via g-tube. During an observation, LVN C was seen crushing four pills together in a single pouch, pouring the combined crushed medications into one cup, then adding approximately 110 mL of water before administering the mixture through the resident’s g-tube. She flushed the g-tube before and after giving the combined medications and then administered the feeding formula, and the resident did not show signs of discomfort or distress during the procedure. In interviews, LVN C stated she always combined and crushed this resident’s medications, explaining that she had heard other nurses administered crushed medications one by one but felt that doing so would take too long, and that no one had told her not to mix them together. She also acknowledged she did not realize she had used so much water and usually used about 30 cc, and that cocktailing medications could possibly affect their effectiveness. The ADON and DON both reported they were not aware that LVN C was mixing the resident’s medications and stated that g-tube medications should be crushed, placed in separate cups, and administered one at a time with water flushes between each medication, and that mixing medications should only occur with a physician’s order. Review of the facility’s “Administering Medications through an Enteral Tube” policy confirmed that medications were not to be mixed together prior to administration through an enteral tube, that each medication should be administered separately unless there was a physician’s order to mix them, that crushed medications should be diluted with 15–30 mL of water, and that 15 mL water flushes should be used between medications when more than one medication is administered.
Failure to Perform Hand Hygiene and Change Soiled Gloves During Incontinence Care and Shower
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care and showering. A female resident with hemiplegia following cerebral infarction, non-Alzheimer’s dementia, aphasia, moderate cognitive impairment (BIMS score of 8), and total dependence for care was observed receiving incontinence care and a shower. She was incontinent of bowel and bladder and required staff assistance for all care, including perineal care with mild cleansers and repositioning. During an observation, CNA A and CNA B prepared to provide incontinence care and a shower. CNA A donned clean gloves and began perineal care after opening the resident’s brief. On the last wipe, brown fecal matter was observed on CNA A’s gloves. After the resident was turned onto her side, CNA A reached over the resident, leaving brown fecal residue on the resident’s left leg and the bed pad. CNA A then used new wipes to clean the resident’s buttocks, during which the resident had a soft bowel movement. After cleaning, CNA A rolled the soiled brief and discarded it, but brown fecal matter remained on her gloves. Without performing hand hygiene or changing gloves, CNA A obtained a clean brief, placed it under the resident’s buttocks, retrieved and placed the Hoyer sling under the clean brief, and assisted in securing the clean brief. Still wearing the same soiled gloves, CNA A retrieved the Hoyer lift, assisted with transferring the resident into the shower chair, and pushed the resident through the hallway into the shower room. CNA A then provided the resident’s shower while wearing the same contaminated gloves used during incontinence care. Once the shower was completed, CNA A removed her gloves and began drying the resident without having performed hand hygiene before or after incontinence care or the shower, and without changing gloves when they became visibly soiled. Interviews with CNA B, CNA A, the ADON, DON, and the Administrator confirmed that facility expectations and written policies required glove changes and hand hygiene when gloves are soiled, when moving from dirty to clean tasks, and when entering and exiting resident rooms, and that failure to do so could cause infection, cross-contamination, spread of germs, or fungal issues.
Failure to Follow Physician Orders for Toe Wound Care
Penalty
Summary
The facility failed to provide proper foot care and follow physician orders for wound care for one resident with a left great toe wound. The resident was an older female with a history of stroke affecting the left side, pressure ulcers, morbid obesity, skin concerns related to mobility issues, and an ADL self-care deficit. A physician’s order dated 02/09/26 directed that Mupirocin 2% ointment be applied to the left great toe twice daily after cleansing with antimicrobial solution and then covering with a dry dressing or bandage. The February 2026 Treatment Administration Record showed no documentation that this wound care was provided twice daily on multiple dates, specifically the 11th, 12th, 13th, 14th, 16th, and 18th. On 02/19/26, surveyors observed that the resident’s left great toe dressing was dated 2/18 and remained unchanged through several observations that day. The treatment nurse stated she handled major wounds while bedside nurses handled minor wounds and believed this resident’s wound care was ordered once daily; she could not explain why the wound care had not been done on 02/19/26. Upon removing the dressing, the treatment nurse observed the toenail was missing with a pink, healthy nailbed and no signs of infection. An LVN working the 6:00 AM–2:00 PM shift stated she normally did wound care at the end of her shift, had not provided this resident’s wound care that day, and was unaware the order was for twice-daily treatment. The regional nurse consultant stated staff followed physician orders for wound care and that the risk of not following the physician’s order was that the physician would be upset. The facility’s wound care policy required verification of the physician’s order and documentation of the date and initials of the person performing wound care.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with pressure ulcers did not receive necessary wound care treatment and services as ordered by the physician on four specific dates. Documentation review revealed that there was no record of wound care being provided on those dates, and the assigned nurse did not document the care or any refusal by the resident. The resident's care plan included interventions for pressure ulcer prevention and treatment, and physician orders specified daily wound care regimens for multiple wound sites. Interviews with facility staff, including the ADON and DON, confirmed that it was the responsibility of the nursing staff to provide and document wound care according to physician orders. Both the ADON and DON were unaware that wound care had not been documented or potentially not provided on the identified dates. The ADON stated that she was not informed of any refusals by the resident, and the DON indicated that wound care might have been provided but not documented. The facility's wound care policy required documentation of wound care, including the date, initials of the person performing care, and any resident refusals or changes in condition. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and type 1 diabetes mellitus, and was assessed as having moderate cognitive impairment. The resident had an unstageable pressure injury, a surgical wound, and a skin tear upon admission. The lack of documentation and uncertainty about whether wound care was provided on the specified dates constituted a failure to ensure the resident received necessary treatment and services consistent with professional standards of practice.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified during a review of the facility's records for a period from April 9, 2024, to July 15, 2024. Specifically, on nine occasions, the facility did not have RN coverage for the required duration. The dates of non-compliance were April 13, May 11, May 12, May 19, June 9, June 15, June 23, July 6, and July 7, 2024. The review of employee time cards revealed that the RNs, including RN Z and the Director of Nursing (DON), worked in shifts that did not meet the eight consecutive hours requirement, often due to breaks or lunch periods. Interviews conducted with the DON and the Administrator revealed a lack of awareness and policy regarding the consecutive RN coverage requirement. The DON, who recently assumed staffing responsibilities, was unaware of the non-compliance and speculated that the issue arose from RNs clocking out for breaks. The Administrator confirmed that the facility did not have a specific policy for RN coverage and instead relied on CMS guidelines. This oversight could potentially place residents at risk of not having their nursing and medical needs adequately met.
Failure to Label IV Medication Leads to Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles, as required by State and Federal laws. This deficiency was observed in the case of a resident who was receiving intravenous (IV) medication. The resident, a male with a diagnosis of sepsis and bacteremia, was prescribed Meropenem to be administered intravenously every eight hours. During a medication pass, the Licensed Vocational Nurse (LVN) responsible for administering the IV medication did not label the IV bag and tubing with the date, time, and her initials, as required by the facility's policy. The LVN acknowledged her failure to label the IV bag and tubing, stating that she was aware of the requirement but had forgotten to do so. She recognized that this oversight could lead to medication errors, such as overdose or omission of a dose, and posed a risk to infection control. The Director of Nursing (DON) confirmed that the expectation was for staff to date and initial IV bags and tubing to track when they were last changed. Despite the training provided, the DON could not specify the risks associated with the failure to label but noted that no adverse events had occurred yet. The facility's policy on IV administration, revised in August 2021, clearly outlined the need to verify and label IV bags and tubing with the date, time, and nurse's initials.
Failure to Accurately Report Licensed Nurse Hours
Penalty
Summary
The facility failed to comply with the mandatory submission of staffing information to CMS, specifically regarding the accurate reporting of licensed nurse hours. This deficiency was identified for eight specific days within the first quarter of the fiscal year 2024. The facility did not submit accurate licensed nurse hours for these dates, which could potentially impact the quality of care provided to residents. The CMS PBJ report indicated that the facility lacked 24-hour licensed nursing coverage on these days, although a review of staff timesheets showed that there was indeed coverage. Interviews conducted during the investigation revealed that the issue stemmed from a problem in the facility's system, which failed to pull the LVN worked hours correctly. The Corporate Analyst responsible for submitting the PBJ staffing information acknowledged the issue and stated that it had been identified and corrected in the previous quarter. The facility's Administrator was unaware of the PBJ staffing report details, as the corporate office handled the reporting. Additionally, the facility did not have a specific policy for PBJ staffing, relying instead on CMS guidelines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 708 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kennedale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Oaks Nursing & Rehabilitation | 3.9 mi | — | 0 | 0 |
| Immanuel's Healthcare | 4.2 mi | — | 2 | 0 |
| Village Creek Nursing & Rehabilitation | 4.8 mi | — | 1 | 0 |
| Tuskegee Airmen Texas State Veterans Home | 5 mi | — | 11 | 3 |
| Matlock Place Health & Rehabilitation Center | 6 mi | — | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Kennedale.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.