Avir at The Lakes

In the surveyor’s words

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

• Immediate jeopardy, patternF689Feb 13, 2022

  Based on observation, interviews, and record reviews the facility failed to ensure the resident's environment remained free of accidents and hazards as is possible for 17 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #18, #19) of 28 residents reviewed for accidents and hazards. The facility failed to supervise residents 7 residents (Resident #1, #2, #4, #5, #6, #8, # 11) of 28 while smoking, Resident #1 burned a hole in his shirt about 1.5 inches in diameter and entered the facility as his shirt was smoking. The facility failed to secure a box containing hazardous smoking paraphernalia (equipment needed for a particular activity) such as cigarettes and lighters, the box and key were easily accessible to residents for all smoking paraphernalia. […]

• Immediate jeopardy, patternF926Feb 13, 2022

  Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 17 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #16, #17, #18, #19) of 28 residents reviewed for smoking. The facility failed to supervise residents 7 residents (Resident #1, #2, #4, #5, #6, #8, # 11) of 28 while smoking, Resident #1 burned a hole in his shirt while smoking unsupervised, he reentered the facility while the shirt was still smoking from the ashes falling on his shirt. The facility failed to secure a box containing hazardous smoking paraphernalia (equipment needed for a particular activity) such as cigarettes and lighters, the box and key were easily accessible to residents. […]

• Immediate jeopardy, isolatedF689Nov 24, 2025

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (CR #1) reviewed for accidents and supervision. - The facility failed to ensure CR #1 had adequate supervision to prevent an accident on 11/4/25 which resulted in a witnessed fall with injury (Acute right subdural hygroma [a collection of cerebrospinal fluid on the right side of the brain beneath the brain's dura mater [the tough, outermost layer that protects the brain and spinal cord]), which resulted in rehospitalization. - The facility failed to ensure 2 staff members remained at bedside during ADL care. […]

• Immediate jeopardy, isolatedF693Jun 20, 2022

  Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate care, treatment, and services to prevent complications for one 1 (Residents #56) of 2 residents reviewed for tube feedings. Resident # 56 was fed hot dog meal for lunch PO diet while he was on NPO from hospital. An Immediate Jeopardy (IJ) was identified on 06/16/22. While the IJ was lowered on 06/19/22, the facility remained out of compliance at scope of isolated with No Actual Harm with Potential for More the Minimal Harm due to the facility's need to monitor the effectiveness of their Plan of Removal corrective system. […]

• Immediate jeopardy, isolatedF684Apr 1, 2022

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (CR #1) reviewed for quality of care. -The facility failed to ensure staff checked on CR #1 who was a full code for approximately 12 hours despite significant changes in the resident's habit of going outside to smoke with other residents (CR#1 missed 3 smoke breaks on [DATE] which was unusual for her). CR #1 was found at approximately 9:45 a.m. on [DATE], unresponsive, cold to touch, skin had begun mottling. She was last seen around 9:00 p.m. […]