F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on,
interview and record review, the facility failed to ensure residents are offered a therapeutic diet when there
is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 1 (Resident # 1)
reviewed for nutrition and hydration:The facility failed to follow Resident #1's physician orders for enteral
feeding.This failure could affect residents receiving enteral nutrition/hydration and place them at risk of
health complications and decline in health. Findings include: Record review of Resident #1's face sheet
dated, reflected an initial admission date of 6/02/2023 and a readmission date of 11/05/2024 with diagnosis
that include UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION (Deficiency of protein and
energy intake), DYSPHAGIA (difficulty swallowing), GASTRITIS, UNSPECIFIED, WITHOUT BLEEDING
(Inflammation of the stomach lining), CEREBRAL PALSY(Abnormal brain development or injury),VITAMIN
D DEFICIENCY, IRON DEFICIENCY. Record Review of Resident # 1's MDS assessment dated [DATE],
reflected a BIMS of 99. The assessment reflected Resident # 1 required extensive assistance with ADLs.
Resident # 1's weight was 161 pounds, and the resident's nutritional approach was feeding tube and
mechanically altered diet. Record review of Resident #1's Order summary report dated 01/29/2026
reflected a physician order to administer at bedtime Nutren 2.0 @65ML/HR Continuously for 10 hours
(8P-6A), providing 1300 kcal,55 gm protein, and 1650ml free water. The physical order had a start date of
11/26/2025 and no end date. Record review of Resident #1's weights from October 2025 to current
reflected there was no weight loss for Resident # 1. Record review of progress note dated 1/28/2026 at
9:38am revealed the NP was notified that Resident #1's tube feeding was not done by night shift nurse. She
ordered staff to encourage him to eat all his breakfast and to monitor any change in condition throughout
day. Record review of meal intake dated 1/28/2026 reflected Resident #1 had eaten 75-100% of breakfast.
In an Interview on 01/29/2026 at 1:15pm, the DON stated Resident #1 missed his nighttime tube feeding
1/27/2026 from 8pm-6am. She stated the night nurse did not give Resident # 1 his feeding. She stated the
NP was notified and ordered staff to encourage Resident #1 to eat all his breakfast and monitor for any
changes in his condition throughout the day. She stated her expectation was that the night nurse should
have followed physician orders and given Resident #1 his nighttime tube feeding of Nutren 2.0 @65ML/HR
continuously for 10 hours (8P-6A). She stated the potential risk of not following physician orders and not
providing enteral feeding to a resident is weight loss or malnutrition. In an interview on 01/29/2026 at
3:20p.m., LVN A stated she did not follow physician orders for Resident #1 and failed to provide Resident
#1's tube feeding of Nutren 2.0 @65ML/HR continuously for 10 hours (8P-6A) on 01/27/2026.She stated
she got confused and thought Resident #1's feeding was to be done during the day shift. She stated that
she should have double checked the physician orders. She stated that the potential risk of not following
physician orders and not providing enteral feeding to a resident is the risk of malnutrition. She stated she
has not worked in the facility since 01/27/2026 and had not received the in-service training yet.In an
interview on 01/29/2026 at 5:23 p.m., the DON stated she
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:
675797
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
675797
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Weston
2505 S 37th St
Temple, TX 76504
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
was currently providing in-service training to staff over PEG tube, following physician orders and
documentation. She stated to ensure Resident #1 did not miss anymore tube feedings, she was calling
Resident #1's night nurse to ensure the tube feeding was done. She stated during the morning stand-up
talks with staff she would remind them of tube feeding. In an Interview on 01/29/2026 at 5:42 p.m., LVN B
stated he received in -service training over peg tube feeding, following physician orders, and
documentation. He stated the negative outcome of not following physician orders and not providing tube
feeding is the potential of weight loss. In an interview on 01/29/2026 at 6:00 p.m., LVN C she stated she
received in -service training over PEG tube feeding, following physician orders, and documentation. She
stated a negative outcome of not following physician orders and not providing tube feeding is the potential
for weight loss and malnutrition. Record review of in-service records titled PEG tube, orders and
documentation dated 01/29/2026 revealed LVN B, LVN #3 and DON completed the training. Record review
of nutrition Risk assessment dated [DATE] at 10:02am reflected most recent weight of 168 pounds, Height
of 64inches and BMI of 28.8. Record review of facility's current Enteral Nutrition policy and procedure dated
November 2018 reflected Adequate nutritional support through enteral nutrition is provided to residents as
ordered.
Event ID:
Facility ID:
675797
If continuation sheet
Page 2 of 2