Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide pharmaceutical services including
procedures that assures the accurate dispensing and administering of all drugs and biologicals to meet the
needs of each resident for one (Resident #1) of four residents reviewed for medication administration. The
facility failed to ensure Resident #1 had received her medications as scheduled and as ordered by her
physician. This failure placed residents at risk for decreased quality of life, unrelieved pain and
misappropriation or property. Findings included: Review of Resident #1's admission MDS, dated [DATE],
revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with the diagnoses
that included cirrhosis of the liver (severe scarring of the liver), metabolic encephalopathy (change in how
your brain works due to an underlying condition), chronic hepatitis (long-term inflammation of the liver) and
depression (serious mood disorder causing persistent sadness and loss of interest). The MDS assessment
reflected Resident #1's BIMs was an 8 indicating moderately impaired cognition. The MDS assessment
revealed Resident #1 received antidepressant medication. The MDS assessment revealed Resident #1
received scheduled pain medication. The MDS assessment revealed when Resident #1 was asked Have
you had pain or hurting at any time in the last 5 days the answer was no. The MDS assessment revealed
resident had experienced PTSD. Review of Resident #1's January 2026 Physician Orders reflected the
following: Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG. Give one tablet by mouth three times a
day for pain. Ordered by LVN C on 01/10/26. Review of Resident #1's January 2026 Physician Orders
reflected the following: Sertraline HCL Oral Tablet 50 MG. Give one tablet by mouth at bedtime for
depression. Ordered by LVN C on 01/09/26. Review of Resident #1's Medication Administration Records for
January 2026 documented by MA A and MA B revealed the resident had missed her
Hydrocodone-Acetaminophen (pain medication) dose on the following dates:01/12/26 at 2PM and
8PM01/13/26 at 8AM, 2PM and 8PM01/14/26 at 8AM, 2PM and 8PM01/15/26 at 8AM, 2PM and 8PM
Review of Resident #1's Medication Administration Records for January 2026 documented by MA B
revealed the resident had missed her Sertraline (antidepressant medication) on the following
dates:01/12/26 at 8PM01/13/26 at 8PM01/14/26 at 8PM01/15/26 at 8PM Review of Resident #1's
Medication Administration Records for January 2026 revealed a pain level of zero for 01/10/26-01/16/26.
Review of Resident #1's nursing progress notes dated 01/11/26 - 01/16/26 revealed no indicators of pain or
discomfort. Review of Resident #1's Pain Interview dated 01/12/26 revealed Resident #1 was experiencing
pain as rarely or not at all. Review of Resident #1's care plan dated 01/08/26 revealed the resident had the
following problems addressed: 1) liver disease related to hepatitis with intervention give medications as
ordered. Monitor/document effectiveness and side effects. 2) uses antidepressant medication with
intervention administer antidepressant medications as ordered by physician. Interview and record review on
01/16/26 at 12:30 PM with the DON of Resident #1's January 2026 physician orders and medication
administration records. The DON acknowledged that Resident #1 had an
(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 3
Event ID:
675374
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
675374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Irving
619 N Britain Rd
Irving, TX 75061
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
order as of 01/10/26 for Hydrocodone-Acetaminophen oral tablet 7.5-325 MG, TID for pain. The DON stated
that the medication administration times for a medication with an order of TID were 8AM, 2PM and 8PM.
The DON reviewed Resident #1's medication administration records and acknowledged that Resident #1
did not receive her Hydrocodone-Acetaminophen as ordered on the following days and times: 01/12/26 at
2PM and 8PM, 01/13/26 at 8AM, 2PM and 8PM, 01/14/26 at 8AM, 2PM and 8PM and 01/15/26 at 8AM,
2PM and 8PM. The DON acknowledged that Resident #1 had an order as of 01/09/26 for Sertraline HCL 50
MG at bedtime. The DON stated that the medication administration time for medication with an order of HS
was at 8PM. The DON reviewed Resident #1's medication administration records and acknowledged that
Resident #1 did not receive her Sertraline on the following days: 01/12/26 at 8PM, 01/13/26 at 8PM,
01/14/26 at 8PM and 01/15/26 at 8PM. The DON stated that if a medication was administered it would have
been signed as given by the MA or nurse on the medication administration record. The DON stated that the
expectation is for medications to be given according to physician orders. The DON stated the risk of not
following physician orders could result in a drug diversion. The DON stated she did not have any knowledge
of Resident #1 not receiving her medications as ordered, therefore she did not know why they were not
given as ordered. Observation on 01/16/26 at 12:45 PM with the DON and MA A of Resident #1's
medications on MA A's medication cart revealed the DON reconciled Resident #1's number of
Hydrocodone-Acetaminophen tablets on hand which confirmed that Resident #1 had not been given her
Hydrocodone-Acetaminophen as ordered. The DON reconciled Resident #1's number of Sertraline HCL
tablets on hand which confirmed that Resident #1 had not been given her Sertraline HCL tablets as
ordered. Interview on 01/16/26 at 1:50 PM with Resident #1 revealed resident was alert and able to answer
questions. Resident #1 stated she had just returned from a luncheon/shopping outing with other residents
and the Activity Director. Resident #1 stated she had a good time on the outing and was not in any pain.
Resident #1 stated she was getting rest and was without pain. Resident #1 stated she was not aware of
missing her medications. Resident #1 had no concerns regarding her care. Interview on 01/16/26 at 2:04
PM with MA B revealed she was responsible for Resident #1's medications on the 2PM-10PM shift
Monday-Friday. MA B stated she did not know Resident #1's Hydrocodone-Acetaminophen and Sertraline
HCL were not given as ordered. MA B stated that when a medication is given it is documented on the
medication administration record, and if it is blank then the medication was not given. MA B stated she had
seen Resident #1 all week and she did not report any issues with pain or discomfort. MA B stated
medications are given according to physician orders. MA B stated the risk of not giving medications as
ordered could result in a resident not feeling good. Interview on 01/16/26 at 2:13 PM with MA A revealed
she was responsible for Resident #1's medication on the 6AM-2PM shift Monday-Friday. MA A stated she
did not know Resident #1's Hydrocodone-Acetaminophen was not given as ordered. MA A stated if a
medication is administered then it is documented on the medication administration record, and if there is a
blank on medication administration record then it was not given. MA A stated it is her responsibility to give
medications according to physician orders. MA A stated the risk of not providing medications as ordered is
not meeting the residents' needs. Interview on 01/16/26 at 2:30 PM with the Activity Director revealed
Resident #1 did attend an offsite luncheon/shopping trip today. The Activity Director stated Resident #1 did
not complain of pain or discomfort while on the outing. The Activity Director stated that Resident #1 enjoyed
herself on the outing. Interview on 01/16/26 at 3:25 PM with the DON revealed she just did not understand
how MA A and MA B would have missed administering Resident #1's Hydrocodone-Acetaminophen and
Sertraline HCL unless there was glitch in the electronic medical record even though no other missed
medications had been discovered. Interview on 01/16/26 at 3:30 PM with the ADM revealed he was not
aware of Resident #1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675374
If continuation sheet
Page 2 of 3
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
675374
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Irving
619 N Britain Rd
Irving, TX 75061
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
not receiving her medications as ordered. The ADM stated that the expectation was for residents to receive
their medications as ordered. The ADM stated that the risk of residents not receiving medications as
ordered could result in illness or sickness. Review of facility policy titled Documentation of Medication
Administration dated November 2022 revealed A medication administration record is used to document all
medications administered. Review of facility policy titled Physician Orders dated November 2014 revealed
Purpose: The Purpose of this procedure is to establish uniform guidelines in the receiving and recording of
physician orders to ensure resident receives the necessary care and services. 5. Physician orders are
essential for the comprehensive care of the residents.
Event ID:
Facility ID:
675374
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the January 16, 2026 survey of Avir at Irving?
This was a inspection survey of Avir at Irving on January 16, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Avir at Irving on January 16, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.