Avir at Arlington

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 5 residents (Residents #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene after glove changes during incontinence care for Resident #1. This failure could place residents at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 1 of 5 quarters (Quarter 2 of 2025) reviewed for RN coverage. 1. The facility failed to have 8 consecutive hours of RN coverage for 15 of 31 days in January 2025.2. The facility failed to have 8 consecutive hours of RN coverage for 25 of 28 days in February 2025.3. The facility failed to have 8 consecutive hours of RN coverage for 5 of 31 days in March 2025. This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #26, Resident #62, and Resident #63) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #26, Resident #62 and Resident #63 were given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) form when discharged from skilled services at the facility. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident's and representative for 2 of 8 residents (Resident #10 and Resident #11) reviewed for comprehensive care plans. The facility failed to invite Resident #10 and Resident #11's resident representative to participate in the residents' care plan meetings. The failure could place residents at risk of their care plans not including resident-specific needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 17 residents (Resident #14, Resident #2 and Resident #60) reviewed for environmental conditions.1. The facility failed to ensure flooring was replaced in Resident #14's room. 2. The facility failed to ensure the faucet knob was replaced in Resident #2 and #60's bathroom. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 8 residents (Resident #11) reviewed for accident hazards. The facility failed to assess Resident #11 for the ability to self-administer a dietary supplement, Gelatide Dietary Supplement, which was kept in her room at her bedside. This failure could affect residents by placing residents at risk of consuming unsafe medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of two medication carts (station one) reviewed for pharmacy services. The facility failed to ensure the station one nurses' medication cart contained accurate narcotic logs for Resident #21 on 02/25/26. This failure could place residents at risk for medication error, and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Residents #1 and #3) of four residents reviewed for care plans. The facility failed to follow Resident #1's care plan. The resident's wound site was not monitored for signs/symptoms of infection, the effectiveness of treatment, and the physician was not notified for wound changes. The resident was sent out on pass with her family on 12/25/25. The RP took her to the hospital the same night and was told the resident had sepsis due to an infection of the wound. The resident did not recover and passed away on 01/03/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #1 and #2) of four residents reviewed for pressure ulcers. The facility failed to ensure Resident #1 received the physician ordered treatment for her pressure ulcer. Staff did not consult with the facility physician or wound care nurse practitioner when the wound started deteriorating. The ulcer worsened and the resident required hospitalization on 12/25/25. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #1) of four residents reviewed for physician notification. The facility failed to notify Resident #1's physician when there was a significant change in her wound status on 12/22/25. The resident was sent out on pass with her family on 12/25/25. The RP took her to the hospital the same night and was told the resident had sepsis due to an infection of the wound. The resident did not recover and passed away on 01/03/26. On 01/08/26 at 5:10PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS Assessment accurately reflected the resident's status for (Residents #3) of four residents reviewed for MDS Assessments. The facility failed to ensure Resident #3's MDS Assessment was correct. This failure could place residents at risk of not receiving care for issues not addressed in the MDS assessment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure 1 (Resident#1) out of 4 residents received adequate supervision and assistance devices to prevent incidents. The facility failed to provide Resident#1 with adequate supervision when transferring her on 10/09/25. This failure could result in falls, injuries and a decline in quality of life.

Inspectors wroteBased 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 of 1 kitchen reviewed for food and nutrition services. 1. Cook G failed to wear a beard guard while prepping food. 2. The facility failed to ensure foods in the refrigerator were properly stored, labeled with the item's contents, and dated with the date in which the food was to be used or discarded. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of residents' personal and medical information for 1 of 4 medication carts reviewed for clinical records on Station 3. MA E failed to lock and secure the laptop on medication cart on Station 3. This failure could affect 48 residents by placing them at risk of resident-identifiable information being accessed by the public.

Inspectors wroteBased on observations, interviews, and record review the facility failed to properly secure medications in locked compartments for 1 (Station 3) of 4 medication carts reviewed for drug storage. MA E failed to lock and secure the medication cart on Station 3. This failure placed 48 residents at risk for their identifiable information accessed by anyone who had unauthorized access to the medication cart and consumption of harmful medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate residents' food intolerances and preferences for 1 of 5 residents (Residents #43) reviewed for food preferences. The facility failed to provide daily oatmeal as requested for Resident #43. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 7 residents (Resident #28) reviewed for physical environment. The facility failed to ensure the call system in Resident #28's room was functioning properly. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for three (Residents #34, #9, and #11) of four residents reviewed for resident rights. The facility did not ensure CNA Y treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased 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 one of one kitchen reviewed for kitchen sanitation. Cook Z and [NAME] X failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (Resident #23) of five residents reviewed for accurate assessments in that: Resident #23's depression was not listed as an active diagnosis on his MDS assessment. This deficient practice could affect residents who receive MDS assessments and could result in missed care.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment with the PASRR program for two (Residents #23 and #29) of five resident assessments reviewed for PASRR evaluations. 1. The facility did not refer Resident #23 to the appropriate state-designated mental health authority for review when he received new diagnoses of schizoaffective disorder, bipolar type; paranoid schizophrenia, bipolar type; and major depressive disorder. 2. The facility did not refer Resident #29 to the appropriate state-designated mental health authority for review when he received new diagnoses of schizophrenia and bipolar disorder. These failures could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services for two (Residents #22 and #30) of five residents reviewed for PASRR Level 1 screenings. 1. The facility failed to follow up on Resident #22, who was PASARR Level I negative on admission with a diagnosis of mental illness and submit another PASARR Level I to the local authority for further evaluation to determine need for specialized services. 2. The facility did not correctly identify Resident #30 as having a mental illness and did not complete a new PASRR Level One Screening. These failures could place residents at risk of not being evaluated for PASRR services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #32 and Resident #41) of six residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Residents #32 and #41's use of TED compression hose. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents who were unable to carry out activities of daily living the necessary services to maintain good personal hygiene to dependent residents for 1 resident (Resident #29) of 5 reviewed for ADL care: -The facility failed to ensure that Resident #29 was accommodated with all bathing needs to receive a proper bath/shower on a routine basis. This failure could place all residents who are dependent on staff for showers/baths at risk of a decreased quality of life, poor hygiene, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #32 and #41) of six residents reviewed for quality of care. The facility failed to ensure Resident#32 and Resident #41 were wearing TED compression hose as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident (Resident #40) of five residents reviewed for enteral nutrition. The facility failed to provide Resident #40 his tube feeding as ordered by the physician. This failure could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one (Station 1 medication cart ) of two medication carts reviewed for medication storage. The facility failed to dispose of two expired vials of insulin and four pieces nicotine gum. This failure could place the residents at risk of not receiving the required therapy or receiving gums that were expired.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for one (Resident #36) of five residents reviewed for adequate monitoring of unnecessary medication. The facility did not monitor Resident #36 for side-effects related to the use of the anti-anxiety medication Buspirone. This failure could place the residents at risk for adverse consequences of medication.