Avir at Cowhorn Creek

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 15, 2025

  Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 13 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. […]

• Immediate jeopardy, patternF675Aug 15, 2025

  Based on observation, interview and record review; it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 13 residents reviewed for Quality of Life. (Resident #1)The facility failed to provide an environment which supported and enhanced the Resident #1's quality of life, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of… […]

• No harm, potential for more than minimal, widespreadF727Feb 12, 2026

  Based 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 1 of 1 facility reviewed for RN coverage. The facility failed to ensure RN coverage for 5 days during FY Quarter 4 2025 (July 1 to September 30). This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care and disasters.The findings included: Record review of the facility payroll-based journal for the fourth quarter of fiscal year 2025 reflected the facility did not have RN coverage on the following days: 08/28/2025, 08/29/2025, 09/01/2025, 09/02/2025, and 09/03/2025. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure equipment surfaces were kept clean.2. The facility failed to ensure that all food items in Refrigerator #1, Refrigerator #2, and Freezer #1 were dated and labeled.3. The facility failed to ensure that the outside of the fryer and the side of the range facing the fryer were kept free of grease build up.These failures could place residents at risk of foodborne illness and food contamination.Record review of a blank Daily Cleaning Schedule indicated the cooks were to clean the stove and cook area after each meal.Record review of a blank Weekly Cleaning… […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2024

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure the sugar was stored in a bin with a closed lid. 2. The facility failed to ensure all food items were labeled and dated in Freezer #1. 3. The facility ensure the deep fryer was clean free of grease splashes and food particles. 4. The facility failed to ensure the doors of Freezer #1, Refrigerator #1 and the lid of the milk cooler was clean and free of food smears. […]