F 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility failed to ensure that residents receive proper
treatment and care to maintain mobility and good foot health by providing foot care and treatment, in
accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for foot
care.The facility failed to follow physician orders for Resident #1's wound care on her toe.This failure could
place residents with wounds to their feet at risk of not receiving proper foot care and developing infections
in their wounds. Findings included: Record review of Resident #1's quarterly MDS assessment, dated
12/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses
which included a stroke that affected the left side of her body, pressure ulcers, and morbid obesity. Record
review of Resident #1's care plan, dated 09/23/25, reflected she had skin concerns related to mobility
issues, and ADL self-care deficit related to her stroke. Record review of physician orders revealed an order
dated 02/09/26 for Mupirocin Ointment 2% (an antibiotic ointment used to treat bacterial skin infections) to
be applied to the left great toe two times a day. Cleanse with antimicrobial solution, apply mupirocin, and
cover with dry dressing or band aid.Record review of Resident #1's February 2026 Treatment
Administration Record reflected there was no documentation by the nursing staff showing that wound care
was provided twice a day on February 11th, 12th, 13th, 14th, 16th, and 18th. Record review of progress
notes indicate on 02/09/26 Resident #1's left great toenail was removed due to ingrown toenail. During an
observation on 02/19/26 at 10:20 AM, Resident #1 was observed to have a dressing on her left great toe
dated 2/18. The dressing was clean, dry and intact. Interview attempt on 2/19/26 at 10:20 AM with Resident
#1 was unsuccessful, resident was non-verbal. Observation on 2/19/26 at 12:20 PM, revealed Resident
#1's dressing remained unchanged. During an observation and interview on 02/19/26 at 2:30 PM, Resident
#1's dressing remained unchanged. The Treatment Nurse stated she provided wound care for major
wounds (pressure ulcers) and minor (cuts, and abrasions) wound care was done by the bedside nurse. She
stated Resident #1's wound care was to be done once a day. She stated she did not know why the wound
care had not been done on 02/19/26. During an observation Resident #1's dressing was removed by the
Treatment Nurse, left great toe toenail was missing, the wound bed was observed to have pink healthy
tissue present in the nailbed, and no redness or indication of infection was observed. The Treatment Nurse
stated the risk of not providing wound care twice a day was the wound getting infected. Interview on
02/19/26 at 2:35 PM, LVN A stated she normally did wound care at the end of her shift (6:00 AM-2:00 PM)
and she had not provided Resident #1's wound care. LVN-A stated wound care was once a day. She stated
she was not aware Resident #1's order was for twice a day wound care. She stated the risk of not following
the physician's order for twice a day wound care was the wound getting infected. Interview on 02/19/26 at
2:49 PM, the Regional Nurse Consultant stated staff followed physician orders for wound care. She stated
the risk of not following the physician's order was the physician would be upset. Record review of the
facility's policy Wound Care, dated October 2010,
Residents Affected - Few
(continued on next page)
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
Page 1 of 2
Event ID:
675270
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675270
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/19/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Kennedale
413 E Mansfield Cardinal
Kennedale, TX 76060
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0687
reflected: Preparation:1. Verify the physician's order for the procedure.Documentation:1. The date the
wound care was given2. The initials of the individual performing the wound care.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675270
If continuation sheet
Page 2 of 2