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Complaint Investigation

Avir At Woodlands

April 2, 2025 · Eastland, TX · 125 Inspiration Blvd
Citations 2
CMS Rating 1/5
Beds 76
Provider ID 675001
Healthcare Facility
Avir At Woodlands
Eastland, TX  ·  View full profile →
Inspection Summary

Avir at Woodlands in EASTLAND, TX — inspection on April 2, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF600
Immediate above residents did not feel safe when transported by facility van. The residents' stated van is not in good Some #10 revealed Resident #10 did not feel safe when transported by facility staff due to staff did not follow affected

During an interview 04/02/2025 at 08:10 AM, Transport aide B stated she/he had in-service on neglect on 04/01/2025 by DON.

Transport aide B stated had been re-trained on use of seatbelts in van, in-serviced on new van orientation for calling 911 and notifying ADM if a resident slid out of wheelchair or got any injury during transport.

Transport Aide B stated she was observed driving the van and parking the van, following speed limit, and parking the van, and securing resident in wheelchair in van with seat belt secured.

Transport Aide B stated she had watched a YouTube video on van transportation and securing a wheelchair in van.

Transport Aide B stated completed a competency for seat belts and safety in the van on 04/01/2025.

During a record review on 04/01/2025 at 08:20 AM record review of facility's Ad-Hoc QAPI held on 03/31/2025 with Medical Director, ADM, DON, ADON, Regional Nurse Consultant that reviewed the alleged deficiency, policy and procedures and transport injury.

Record review of Van Driver Orientation List for Transport Aide F on 04/01/2025 at 08:25 AM revealed training completed on 03/25/2025 that consisted of securing a wheelchair in the facility van and securing a resident in a wheelchair with seat belt.

The training included a return demonstration of securing a wheelchair and securing a resident in a wheelchair with a seat belt.

During a record review on 04/01/2025 at 08:30 AM of Van Driver Orientation List for Transport Aide F revealed training completed on 11/14/2024.

Record review04/01/2025 at 08:35 AM of Resident #10's EMR progress notes dated 03/26/2025 revealed a physical assessment of the resident by DON after returning from van transport.

The physical assessment revealed resident sustained an 25 cm abrasion to his lower back.

675001

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675001 B.

Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

During an interview on 03/28/2025 at 09:10 AM, CNA A stated she was in-serviced on 03/27/2028 by DON on resident rights, secure unit staffing, one on one, exit seeking, and elopement on 03/27/2025 by DON. CNA A stated one on one was making sure resident was in line of sight and staying with them and not helping with other residents. CNA A stated the secure unit should have 2 staff on all shifts, if resident was exit seeking should try to redirect and call for help if needed. If a resident elopes, she was to try to find the resident, let the charge nurse know, do room check and head count.

Residents have the right to make their own choices, refuse care, and know what medicines they are getting.

During an interview on 03/28/2025 at 09:15 AM, NA G stated she was in serviced on 03/27/2025 by DON resident rights, one on one, staffing of secure unit, exit seeking and elopement on 03/27/2025 by DON.

Staffing of secure unit with at least 2 staff unit each shift. NA G stated one on one meant always keeping resident in line of sight. NA G stated if residents were exit seeking to try to redirect or see if they are hungry. NA G stated residents had the right to refuse care, treated with respect, and make decisions.

During an interview on 03/28/2025 at 09:20 AM, LVN H stated she was in-services on 03/27/2025 by DON on One-to One, Staffing on Secured Unit, Resident Rights, Exit Seeking, and Elopement on 03/27/2025 by DON. LVN H stated one on one meant keeping resident in line of sight and not leaving resident until another staff member can take over one on one. LVN H stated the secure unit should have been staffed with 2 staff at all times. LVNH stated if a resident was exit seeking staff should try to re-direct resident, offer food or see if the resident was in pain. LVN H stated residents had the right to refuse care, to be treated with respect and to make their own decisions.

675001

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675001 B.

Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EASTLAND, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Woodlands or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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