Avir at Rose Trail

In the surveyor’s words

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

• Immediate jeopardy, patternF580Aug 14, 2026

  Based on observation, interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident's #1) reviewed for a change of condition. 1. The facility failed to notify the physician and document an assessment and communication with the physician on 8/5/2026, 8/7/2026 and 8/8/2026 when Resident #1 was exhibiting symptoms of a stroke. 2. The facility failed to follow their Change of Condition Policy by utilizing the SBAR communication form to document the communication with the MD on 8/5/2026, 8/7/2026 and 8/8/2026. […]

• Immediate jeopardy, patternF684Aug 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 7 residents reviewed for quality of care.1. The facility failed to address Resident #1's history of a stroke and disorder of brain circulation as a medical diagnoses in the facility's EMR. Resident #1's medical records did not include signs or symptoms of a stroke or brain circulation complication to monitor for.2. The facility failed to document assessments/findings on Resident #1 related to displayed stroke symptoms on 8/5 per the facility's change of condition policy.3. […]

• Immediate jeopardy, patternF695Oct 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide respiratory care, including tracheostomy care and tracheal suctioning consistent with professional standards of practice, the resident's care plan, and the resident's preferences, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure LVN C assessed Resident #1 when he exhibited abdominal retractions (a sign of respiratory distress) while breathing on 09/24/25. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. […]

• Immediate jeopardy, patternF880Oct 2, 2025

  Based 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 development and transmission of communicable diseases and infections for 5 of 5 residents (Resident's #1, # 2, #3) reviewed for infection control practices. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. […]

• Immediate jeopardy, patternF684Apr 3, 2024

  Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. 1.The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection). […]