Avir at Walnut Springs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #4 and #52) of 4 residents reviewed for incontinence care. The facility failed to ensure while providing incontinent care: 1. CNAB did not clean the right buttock area for Resident #4. 2. CNAC did not separating the labia and thoroughly clean the vaginal area for Resident #52. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections. The findings included: 1. Record review of Resident #4's face sheet, dated 09/26/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnosis of severe protein-calorie malnutrition (a nutrition status in which reduced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 (stage 2 station medication room) of 1 medication room, 1 (stage 1 station medication aide cart) of 3 medication carts, and 1 resident (Resident #64) of 25 residents reviewed for storage, in that: The facility failed to ensure: 1. There was one bottle of Fish Oil 1200 mg found in stage 2 station medication room on 09/24/2025, and it expired 07/2025. 2. Resident #64's acetaminophen suppository was found in the refrigerator inside stage 2 station medication room on 09/24/2025, and it expired 08/2025. 3. There was one bottle of calcium citrate with vitamin D3 found in stage 1 station medication aide cart on 09/24/2025, and it expired 07/2025. This failure could place residents at risk of misappropriation of medications and not having the intended therapeutic effects.The findings were: 1. Observation on 09/24/2025 at 2:39 p.m., of the stage 2 station medication room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide assessments that accurately reflect the resident's status for two of seventeen (Residents #3 and #74) residents reviewed for MDS assessment accuracy. The facility failed to ensure: 1. Resident #3's quarterly MDS assessment did not accurately reflect he had a Bi-Pap (Bi-level positive airway pressure) for helping his breathe. 2. Resident #74's discharge MDS assessment did not accurately reflect death in the facility. This deficient could place residents with MDS assessments at risk of missed or inappropriate care.The findings included: 1.Record review of Resident #3's face sheet, dated [DATE] reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hypothyroidism (the thyroid gland does not make enough thyroid hormone), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), heart failure (the heart muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #70) of three residents who was reviewed for respiratory care. The facility failed to ensure Resident #70's suction Yankauer (suctioning tool used in medical procedures. It is typically a firm plastic suction tip with a large opening to allow effective suction in the mouth) which was attached to a suction machine was not covered in a plastic bag when the facility did not use it. This deficient practice could place residents who receive respiratory therapy and could contribute to respiratory distress, infections, pneumonia and an overall decline in their physical condition.The findings were: Record review of Resident #70's face sheet, dated 09/26/2025, revealed the resident was 78-years-old male who was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 (stage 2 station medication room) of 2 medication rooms. The facility failed to ensure all prepared items in the refrigerator located inside the stage 2 station medication room was labeled and dated with the use by date. These failures could place residents at risk for food borne illness.The findings included: Observation of the facility's stage 2 station medication room on 09/24/2025 at 2:39 p.m., revealed there was two refrigerators in the medication room. One was for the medications, and the other was for the residents' food. There was 4 small containers with food found in the stage 2 station medication room, and the food containers did not have any labels or dates. During an interview on 09/24/2025 at 2:39 p.m., ADONE stated there was 4 small containers with food found in the stage 2 station medication room, and the food containers did not have any labels or dates. ADONE said the food looked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #21) of 25 residents reviewed, in that: Resident #21's personal refrigerator had unlabeled and undated food. The failure could place the resident at risk for food borne illness.The findings were: Record review of Resident #21's face sheet, dated 09/26/2025, revealed the resident was 85-years-old male and admitted to the facility on [DATE] with diagnoses of dementia (loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities), muscle wasting and atrophy (loss of skeletal muscle mass), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), dysphagia (difficulty swallowing), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that each resident received adequate assistance devices to prevent accidents for 2 of 2 Residents (Resident #1 and Resident #2) who were observed for mechanical lift transfers. 1. CNA A and CNA B failed to lock and widen the base of the mechanical lift while transferring Resident #1 from the wheelchair to the bed. 2. CNA C and CNA D failed to position the mechanical lift in a manner that would allow staff to widen the base of the mechanical lift while transferring Resident #2 from the Geri-chair to the bed. These deficient practices could affect residents who used a mechanical lift for transfers and contribute to avoidable falls. The findings were: 1. Review of Resident #1's face sheet, dated 5/2/25, revealed she was admitted into the facility on 7/11/25 with diagnoses including unspecified Dementia, contracture left knee and left ankle. Review of Resident #1's quarterly MDS assessment, dated 2/22/25, revealed her BIMS score was 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 22 residents (Resident #21) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #21. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #21's face sheet, dated 08/27/2024, revealed she was admitted to the facility on [DATE] with a latest return date of 12/29/2021 with diagnoses which included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, vascular dementia severe, without behavioral disturbance, pain disorder with related psychological factors, anxiety disorder, schizoaffective disorder, depressive type, and hypertension. Record review of Resident #21's Quarterly MDS assessment, dated 06/26/2024, revealed the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were not verbally and physically abused for 1 of 8 Residents (Resident #5) whose records were reviewed for abuse. CNA B roughly rolled Resident #5 forward in bed applied a mechanical lift sling and roughly rolled Resident #5 back towards her in bed preparing Resident #5 for a mechanical lift transfer. CNA B told Resident #5 to shut up when Resident #5 moaned and groaned. CNA B told Resident #5 Don't grab me. when Resident #5's right hand slightly touched her right shoulder due to the force used when rolling Resident #5 back towards her. CNA B then commented, Same shit every day; every day. This noncompliance was identified as past non-complinace. The non-complinace began on 08/15/2024 and ended on 08/18/2024. The facility corrected the non-complinace before the survey began. This deficient practice could affect any resident and result in emotional and physical abuse. The findings were: Review of Resident #5's face sheet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review revealed based on the comprehensive assessment of a resident, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 Residents (Resident #2) whose records were reviewed for wounds. Nursing staff failed to ensure treatment orders were entered into Resident #2's EHR after she was assessed with an anal fissure (a small tear in the thin, moist tissue that lines the anus according to Mayo Clinic) to ensure Resident #2 received treatment per physician's orders. This deficient practice could affect residents with new physician orders and could contribute to a decline in physical condition. The findings were: Review of Resident #2's quarterly MDS assessment, dated 7/17/24, revealed she was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Schizoaffective Disorder and Chronic Kidney Disease, Stage III. Further review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 2 of 8 Residents (Resident #5 and Resident #36) who were observed for transfers. 1. CNA B transferred Resident #5 from the bed to the wheelchair using a mechanical lift which by the resident's care plan and policy required two people for operation and transfer. 2. CNA C transferred Resident #36 from the wheelchair to the bed without the use of a gait as needed due to the resident having unsteady gait. These deficient practices could affect residents who require assistive devices during transfers and could contribute to avoidable falls. The findings were: 1. Review of Resident #5's face sheet, dated 8/27/24, revealed she was admitted to the facility on [DATE] with diagnoses including Malignant neoplasm of upper-inner quadrant of unspecified female breast; unspecified protein-calorie malnutrition; Contracture, unspecified hand, Contracture, unspecified knee and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.