Avir at Arlington

In the surveyor’s words

From the most serious findings on record at Avir at Arlington, in the surveyor’s own words.

• Immediate jeopardy, patternF656Jan 10, 2026

  Based 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. […]

• Immediate jeopardy, patternF686Jan 10, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF580Jan 10, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Sep 1, 2022

  Based on observation, interview and record review the facility failed to ensure residents received adequate supervision for 1 of 1 resident (Resident #1) reviewed for safety and supervision. The facility failed to ensure Resident #1 who had cognitive impairment had supervision at a physician's appointment outside of the facility. Resident #1 left the faciity on [DATE] at 6:55 AM to attend his appointment and left the appointment on his own. He was gone from the facility for 35 hours. The resident returned to the facility at on 8/27/22 at 6:00 PM. The facility staff failed to follow the facility's protocol related to missing residents. The facility did not have a policy related to transportation of residents to include supervision. […]

• No harm, potential for more than minimal, widespreadF727Feb 26, 2026

  Based 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. […]