Avir at Fort Worth

In the surveyor’s words

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

• Immediate jeopardy, patternF600Feb 22, 2023

  Based on observation, interview, and record review, the facility failed to provide services to prevent neglect for 1 of 5 residents (Resident #1) reviewed for neglect. Resident #1 had an elopement attempt on 10/15/22 where he sat on the facility side street and when found he voiced that he wanted to go home and he had a decrease in his BIMS on 11/10/22 from 13 to 11. The facility failed to address the concerns, assess for elopement, or revise care plan. Resident #1 eloped from the facility on 2/16/23 and his location was unknown for 4 days during freezing temperatures with lows of 27 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. […]

• Immediate jeopardy, patternF689Feb 22, 2023

  Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to provide interventions and supervision for Resident #1 from eloping from the facility on 10/15/22 and 02/16/23. Resident#1's location was unknown for 4 days. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. […]

• Immediate jeopardy, isolatedF600Nov 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 3 residents (Resident #1) reviewed for abuse and neglect. CNA C, who was responsible for providing Resident #1 with one-to-one supervision, failed to protect the resident when the resident entered into a verbal altercation with CNA A, which escalated to CNA A spraying [NAME] at the resident on 11/16/25. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. The failure placed residents at risk for serious physical and psychological harm. […]

• Immediate jeopardy, isolatedF609Nov 19, 2025

  Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility for 1 of 3 residents reviewed for abuse and neglect. CNA F and CNA G failed to report to the Administrator when they overheard CNA A threaten to [NAME] Resident #1 during a verbal altercation the morning of 11/16/25. Four hours later, the resident entered into a verbal altercation with CNA A, which escalated to CNA A spraying [NAME] at the resident. The noncompliance was identified as past noncompliance. […]

• Immediate jeopardy, isolatedF684Jun 14, 2024

  Based 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 based upon the comprehensive assessment of a resident for one of three residents (Resident #54) reviewed for quality of care. Agency LVN E failed to properly insert Resident #54's Foley catheter on 03/13/24 by inflating the balloon in the resident's urethra causing urethal trauma and significant bleeding. Resident #54 had to be transported to the hospital where a CT Scan revealed the urinary catheter balloon had been inflated in the resident's urethra causing trauma to the area. […]