Avir at Kingsland

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of (10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25) of 15 days reviewed for RN coverage. The facility failed to ensure they had an RN coverage for the facility on 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25. This failure could place residents at risk of missed nursing assessments, interventions, care and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable food. 1. The facility failed to provide meal services in a manner to ensure palatable food served was appetizing to residents.2. The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #7, #13, and #28. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the 1 of 1 kitchen reviewed. 1. The facility failed to label and date food correctly. 2. The facility failed to staff properly sanitized their hands while passing out trays during food service on 5-26-2026. 3. The facility failed to maintain a clean kitchen, 4. The facility sanitizes the thermometer while taking the temperatures of food. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 3 Residents (Resident #2 and Resident #1) reviewed for pharmacy services.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 24 resident (Resident #50 reviewed for resident rights. The facility failed to ensure the HK knocked on Resident #50's door when entering their room on 5-26-2026. These failures could place residents at risk of poor self-esteem, and not a home-like environment.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs without indications for its use for 2 of 3 Residents (Resident #2 and Resident #1) reviewed for the right to be free from chemical restraints.1. The facility failed to obtain a current active consent from Resident #2's family representative for the use of Quetiapine Fumarate (antipsychotic) used for agitation/anxiety related to dementia, Depakote ER (extended release) antiepileptic/ antimanic, Buspirone (anti-anxiety), Paroxetine (antidepressant), and donepezil (used for dementia) and failed to have an active diagnosis of anxiety and depression to correspond with medications prescribed from November 2025 through May 2026.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 did not experience physical abuse when Resident #1 struck Resident #2 with a cane, resulting in an abrasion on the head on 4/20/26. Findings Included:Resident #1Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses including non-Alzheimer's dementia (a function cognitive decline in memory), alcoholic fibrosis and sclerosis of the liver (scaring of the liver tissue), chronic pain, cataracts (a clouding of the lens on the eye affecting vision), and constipation. The resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident /Resident Representative had the right to be informed of, and participate in, his or her treatment for one (Resident #1) of six residents reviewed for resident rights. The facility failed to notify Resident #1's family when he had a fall on 01/17/2026 during the night shift. This failure could place the residents at risk of not being informed of their health status, in order to make informed decisions regarding their care.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of six residents reviewed for care plans. The facility failed to include in Resident #1's care plan that he had Type 1 Diabetes Mellitus and needed insulin for blood glucose management. [...]

Inspectors wroteBased on interview and record review the facility failed to give each resident a special diet to help when there was a nutritional problem for one (Resident #1) of four residents reviewed for therapeutic diet. The facility failed to administer therapeutic diet for Resident #1 from 12/27/2025 through 12/31/2025 as was recommended by the hospital upon discharge. The failure place residents at risk for aspiration, choking and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to provide therapy services that evaluate and treat a function that was impaired by illness or injury and increased the resident's functioning for one (Resident #1) of three residents reviewed for Rehab services. The facility's failed to ensure the therapy department evaluated Resident #1 upon admission to the facility per physician order. The facility failed to evaluate and treat Resident #1 after a fall on 01/07/2025 as per care plan intervention. This failure placed residents at risk of not being evaluated in order to get appropriate treatment as needed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 2 nurses (LVN A) reviewed for nursing services. The facility failed to ensure LVN A assessed and performed necessary interventions to stop Resident #1 from bleeding from skin tears on 09/13/25. This failure could place residents with wounds at risk for bleeding related complications.

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 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed in notifying Resident #1's physician right away when the resident had a significant change in condition. Resident #1 had was bleeding from skin tears on 09/13/25.) This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 2 of 3 medication carts (MC #1, and TC #2) reviewed for drug storage and labeling. The facility failed to ensure MC #1, and TC #2 were locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observations, interviews, 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 transmission of communicable diseases and infections for 4 of 4 residents (Resident #1, #3, #13, and #51) reviewed for infection control. The facility failed to ensure LVNA sanitized equipment/work surfaces between Residents #1, #3, #13, and #51. This failure could place residents at risk for development of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 4 residents (Resident #3 and #13) reviewed for medication errors. The facility failed to ensure LVN-A administered medications according to physician's order and manufactured guidelines for resident #13 when LVN-A crushed an extended release medication and failed to ensure a medication was in the medication cup. LVN-A failed to give resident #03 the correct number of tablets. This failure could place residents at risk for incorrect dosages resulting in reduced healing and unnecessary hospitalizations.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure expired medications were removed from the over-the-counter medication supply cabinet in the medication storage room. This failure placed residents at risk of not receiving the intended therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident with pureed diet orders receivedfood that was palatable, attractive, and at a safe and appetizing temperature for 11 of 11 residents on pureed diets and 1 of 1 lunch meal tested for nutritive value, flavor, and appearance. The facility failed to provide palatable food served at an appetizing temperature to residents. The facility failed to ensure residents received their meals according to the menu. This deficient practice could place the residents who ate food from the facility kitchen by placing them at risk of poor food intake, weight loss and/or dissatisfaction of the meals served.

Inspectors wroteFACILITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure CK #1 properly sanitized her hands between tasks. The facility failed to ensure DS used the ice scooper when scooping ice out of the ice machine. The facility failed to ensure DM and [NAME] 1 properly wore a hair restraint while in the kitchen. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted as required for 1 of 4 days (01/28/24) reviewed for nursing services and postings. The facility failed to post the required staffing information for 01/28/24. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.