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Complaint Investigation

Avir At Woodlands

August 13, 2025 · Eastland, TX · 125 Inspiration Blvd
Citations 5
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 August 13, 2025.

Found 5 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

FF0655
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

During an observation and interview on 08/12/2025 at 11:35 AM Resident #44 was sitting in her room in her wheelchair. Resident #44 stated she was at facility for breaking her hip.

During an interview on 08/13/2025 at 11:07 AM the RNC stated her expectation was that baseline care plans should have been completed within 48 hours of admission.

The RNC stated she had initiated the baseline care plan for Resident #44 today.

The RNC stated that the baseline care plan had not been completed in the required 48 hours.

The RNC stated the charge nurse, and the DON were responsible for completing the baseline care plan.

The RNC did not provide a reason for what to led to failure.

During an interview on 08/13/2025 at 2:15 PM the DON stated her expectation was baseline care plans should have been completed within the 48 hours of admission.

The DON stated the charge nurse was responsible for initiating the baseline care plan.

The DON stated what led to failure was oversight by staff.

During an interview on 08/13/2025 at 3:30 PM the ADMN stated her expectation was baseline care plans should have been completed within 48 hours of admission.

The ADMN stated the charge nurse was responsible for completing the baseline care plan.

The ADMN stated the DON was responsible for monitoring to ensure the baseline care plans were completed within 48 hours.

The ADMN stated she did not think there was a negative effect on resident not having baseline care completed.

The ADMN did not give a reason for the failure of Resident #44's baseline care plan completed.

Record review of the facility policy titled, Care Plans-Baseline dated March 2022, revealed A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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Facility ID:

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0802 during a standard health inspection conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

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Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0809 during a standard health inspection conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests.

Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

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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