Avir at Garland

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 7, 2022

  Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two of two residents (Residents #1 and #2) reviewed for supervision. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had moderately cognitive impairment, wandering behavior, and lacked safety awareness. Resident #1 eloped from the facility walking to the local pharmacy that was 150 yards away and located on a busy street, the temperture ranged from 48 degrees to 64 degress, and asked to call 911, on 01/08/22 and was brought back to the facility by the emergency services. 2. […]

• Immediate jeopardy, isolatedF689Nov 13, 2025

  Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents which resulted in sustained bleeding to the brain, a bruise to the scalp, and a bruising to the hands for 1 (Resident #1) of 4 residents reviewed for accidents. On 11/07/2025 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, with a sliding board, on Resident #1 who required a 2-person transfer with a Hoyer (Mechanical lifting device to help workers transfer patients) lift for nursing staff. CNA A failed to request assistance from another staff member and was unable to complete the transfer successfully. Resident #1 fell on the floor and hit her head. […]

• Immediate jeopardy, isolatedF689Nov 26, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for elopements. The facility failed to ensure Resident #1 received adequate supervision and remained in the facility's secured care unit, which resulted in her elopement from the facility on 10/04/2024. The facility failed to provide adequate supervision to Resident #1 to ensure Resident #2 did not facilitate Resident #1's elopement on 10/04/2024. The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. […]

• Immediate jeopardy, isolatedF580Aug 12, 2024

  Based on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of six residents reviewed for Change in condition. LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA A asked her to assist with picking Resident #1 off the floormat and putting her back to bed. Subsequently, Resident #1 was sent to the hospital on 08/08/24 and currently at the hospital diagnosed with two fractures (Tibia and Fibula) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/12/24. […]

• Immediate jeopardy, isolatedF600Aug 12, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for Neglect. CNA A failed to ensure Resident #1 did not fall out of bed on 08/02/24 while she was providing incontinent care and LVN B failed to document assessing Resident #1's fall, LVN B failed to notify Resident #1's Doctor, LVN B failed to complete an incident report, and LVN B failed to notify the oncoming Nurse, DON, and Administrator about Resident #1's fall. Subsequently, Resident #1 was sent to the hospital 08/08/24 and was diagnosed with two fractures Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/11/24. […]