Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Arden Wood during CMS and state inspections, most recent first.
Surveyors found that required Enhanced Barrier Precautions (EBP) signage and PPE were missing outside the rooms of three residents with significant medical conditions, despite care plans and facility policy mandating their presence. Staff interviews revealed reliance on such signage to determine appropriate PPE use, and the infection preventionist confirmed ongoing issues with missing signs, leading to lapses in infection control practices.
Surveyors found a bottled water buried in the kitchen ice machine, which the DM removed using an ice scooper. The DM confirmed that personal items should not be stored in the ice to prevent contamination and was unsure who placed the bottle there. Staff had been previously in-serviced on proper ice machine use, and policies were in place for safe food and beverage storage, but these were not followed, resulting in a deficiency.
A resident with multiple complex medical conditions did not receive a required specialized pressure-reducing mattress because the facility failed to submit the PASRR Nursing Facility Specialized Services (NFSS) request within the mandated timeframe, due to identification issues and delays in obtaining supplier documentation.
A resident with diabetes and chronic kidney disease did not have physician-ordered blood sugar reporting parameters in place, leading to multiple high blood glucose readings not being reported to the physician as required by facility policy. Staff interviews revealed inconsistent understanding of when to notify the physician, and documentation showed no evidence of timely communication regarding abnormal blood sugar levels.
A nurse failed to administer a prescribed dose of Lorazepam to a resident with severe cognitive impairment and behavioral issues, despite signing out the medication on the narcotic sheet. The medication was not removed from the blister pack, resulting in inaccurate controlled substance records and the resident not receiving the ordered medication. Interviews and record reviews confirmed the medication error and documentation discrepancy.
Surveyors found that two medication carts contained narcotic pill cards with torn protective seals, including one instance where a Lorazepam tablet compartment was taped closed. Nurses acknowledged the improper handling and stated that damaged tablets should be wasted, not taped. The DON confirmed that such incidents should be reported and that facility policy requires proper storage and inventory of controlled substances.
A facility failed to protect residents from neglect, resulting in an altercation between two residents in the memory care unit. An 84-year-old male resident with a history of aggressive behavior was involved in an incident with a 92-year-old female resident who wandered into his room. The altercation led to injuries for the female resident. The facility's care plans were not adequately updated to address these behaviors, contributing to the incident.
The facility failed to implement comprehensive care plans for two residents, leading to unaddressed aggressive behaviors in one resident and unmitigated fall risks in another. The care plans lacked necessary updates and interventions, resulting in serious incidents and highlighting systemic issues in care plan management.
A resident with schizoaffective disorder and cognitive impairment exhibited aggressive and territorial behaviors, which were documented in progress notes but not reflected in the care plan. Despite incidents of aggression and physical altercations, the care plan was not updated to address these behaviors. Interviews with staff revealed a lack of awareness and action regarding the resident's behavioral issues, contributing to the deficiency in care.
Failure to Maintain EBP Signage and PPE for Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for three residents reviewed for infection control. Observations on multiple occasions revealed that required EBP signage was missing from the doors of rooms where EBP was indicated, and there was no equipment placed outside these rooms to alert staff of the necessary personal protective equipment (PPE) to be used. This was contrary to the facility's own policy and care plans, which specified that signage should be posted to inform staff of required precautions during high-contact care activities. Record reviews showed that the affected residents had significant medical conditions, including obstructive and reflux uropathy, malignant neoplasm of the kidney, sepsis, slow transit constipation, anemia, and heart failure. Their care plans required staff to use gowns and gloves during high-contact care and specified that EBP signage should be posted outside their rooms. However, during the survey, these signs were not present, and staff interviews confirmed reliance on such signage to determine appropriate PPE use before entering rooms. Staff interviews indicated that while in-service training on EBP and PPE had been conducted recently, staff depended on the presence of signage or equipment outside the room to guide their infection control practices. When signage was missing, staff reported they would consult with the nurse or infection preventionist. The infection preventionist acknowledged that EBP signs had been disappearing and required frequent replacement, but at the time of the survey, the necessary signage was not consistently in place for residents requiring EBP.
Improper Storage of Personal Beverage in Kitchen Ice Machine
Penalty
Summary
A deficiency was identified when surveyors observed a bottled water buried within the stored ice of the facility's kitchen ice machine. During the initial kitchen tour, the Dietary Manager (DM) used an ice scooper to remove the 8oz bottled water from the ice. The DM acknowledged that bottled water should not have been placed in the ice and was unaware of who was responsible. He explained that items should not be stored in the ice to prevent contamination. The kitchen had a cart with various beverages containing ice for the morning meal, and the DM noted that there was no designated area in the kitchen for staff to store personal food or beverages, though an employee breakroom was available for this purpose. Further interviews confirmed that both the DM and Corporate DM had previously conducted in-services instructing staff to keep the ice machine free from personal items, including drinks. The DM reiterated that kitchen staff were informed to store personal food and drinks in the breakroom or lockers, and that drinks for hydration could be kept in the DM's office. The Administrator stated that all individuals were expected to follow proper storage protocols to prevent items from coming into contact with the ice, which would render the ice unusable. Policy reviews indicated procedures for safe food handling and storage, but the incident demonstrated a failure to adhere to these standards.
Failure to Submit PASRR NFSS Request for Specialized Mattress
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR) program for a resident who required specialized services under Medicaid. Specifically, the facility did not submit a Nursing Facility Specialized Services (NFSS) request for a specialized pressure-reducing support surface mattress within the required 20 business days following the Interdisciplinary Team (IDT) meeting. The delay was attributed to issues with the resident having two social security numbers, which necessitated repeating the PASRR process, and the inability to obtain a medical equipment supplier quote in time. As a result, the NFSS was not submitted, and the mattress was never ordered before the resident was discharged. Record reviews confirmed that the resident had multiple complex medical diagnoses, including diabetes, severe intellectual disabilities, heart failure, and a pressure ulcer. Interviews with staff revealed that the tracking system for NFSS submissions was in place, but the process was disrupted due to the resident's identification issues and delays in obtaining necessary documentation. Additionally, the facility did not provide a written policy outlining its PASRR process, only supplying state guidance documents upon request.
Failure to Ensure Physician Supervision and Blood Sugar Reporting Parameters for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including Type 2 diabetes mellitus, chronic kidney disease, and hemiplegia, was under appropriate medical supervision as required. The resident was admitted with significant care needs and was dependent on staff for most activities of daily living. Despite being on insulin therapy and tube feeding, there were no physician orders specifying blood sugar parameters for when to notify the physician of abnormal glucose levels, as required by facility policy. Over several days, the resident experienced multiple episodes of elevated blood glucose readings, with values consistently above 300 mg/dl. These high readings were not reported to the physician or the resident's guardian until several days after the initial occurrences. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of protocols for reporting high blood sugar levels, with some staff stating they would report values above 200 mg/dl or 300 mg/dl, while the attending physician indicated she only wanted to be notified for blood sugars below 70 mg/dl or above 400 mg/dl. Documentation showed that no calls were made to the physician regarding the high blood sugar readings, and there was no evidence of physician orders for specific reporting parameters in the resident's chart. The facility's diabetes management protocol required the physician to order parameters for monitoring and reporting blood sugar levels, and for staff to incorporate these into the care plan and medication administration record. However, this was not done for the resident in question. Staff interviews further confirmed that there was confusion and lack of clarity regarding when to notify the physician about abnormal blood sugar levels, and that in-service training had occurred but did not result in consistent practice. The failure to obtain and follow physician orders for blood sugar reporting parameters resulted in a lack of appropriate medical supervision for the resident.
Failure to Administer Medication and Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering medications as ordered and by not maintaining accurate records of controlled substances. Specifically, a nurse signed out a dose of Lorazepam 0.5 mg for a resident with severe cognitive impairment, schizophrenia, anxiety, depression, and dementia, but did not actually administer the medication as prescribed by the physician. The medication administration record was later corrected to indicate the dose was not given, and the nurse acknowledged the error, stating she thought she had dispensed the medication but had not. The resident in question had a history of behavioral symptoms, including agitation, wandering, and refusal of care, and was prescribed antipsychotic, antianxiety, and antidepressant medications. The care plan emphasized the importance of administering medications as ordered and monitoring for side effects and effectiveness. On the day in question, the nurse signed out the Lorazepam on the narcotic sheet, reducing the count, but the blister pack still contained the expected number of tablets, confirming the medication was not removed or given. Interviews with the nurse and the Director of Nursing confirmed that the medication was not administered as ordered and that the recordkeeping for the controlled substance was inaccurate. The facility's policies require medications to be administered as prescribed and for accurate inventory of controlled substances to be maintained at all times. The failure to follow these procedures resulted in the resident not receiving the intended dose of Lorazepam and inaccurate documentation of the controlled drug inventory.
Improper Storage and Handling of Controlled Substances in Medication Carts
Penalty
Summary
Surveyors observed that two medication carts, one in the secured unit back hall and one in the station 1 front hall, contained narcotic pill cards with torn protective seals. In the secured unit, a Lorazepam 0.5 mg pill card had a torn seal on one compartment, which was covered with tape. The nurse present stated that the tablet should have been wasted and not taped, and was unsure who applied the tape or why. In the station 1 front hall, pill cards for Tramadol 50 mg and Lorazepam 1 mg were found with torn seals on several compartments. The nurse acknowledged the risk of tablets falling out or being lost due to the torn seals and stated that the affected tablets should be wasted with another nurse present. The Director of Nursing (DON) confirmed that narcotics are counted at the end of every shift, with additional checks by unit managers and charge nurses. The DON stated that tape should not be used to reseal pill cards and that any damage to the packaging should be reported immediately. Facility policy requires controlled substances to be stored and maintained in locked compartments with accurate inventory at all times. Despite the torn seals, the narcotic log sheets showed correct counts for the medications involved.
Neglect and Inadequate Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure that each resident was free from neglect, as evidenced by an incident involving two residents in the memory care unit. Resident #2, an 84-year-old man with a history of schizoaffective disorder and other conditions, exhibited aggressive and territorial behaviors, particularly when other residents entered his room. Despite these behaviors being documented in progress notes, his care plan did not adequately address these issues. On one occasion, Resident #2 was involved in a physical altercation with another resident, resulting in a traumatic brain injury. Resident #3, a 92-year-old woman with dementia and a tendency to wander, was found injured in Resident #2's room. She had wandered into his room, which led to an altercation where she was struck with a trash can, sustaining multiple injuries. The facility's failure to supervise and manage the behaviors of both residents contributed to this incident. The care plan for Resident #3 noted her wandering behavior but did not effectively prevent her from entering other residents' rooms. Interviews with staff revealed that there were lapses in updating care plans and addressing the behavioral needs of residents. The Unit Manager admitted to not attending care plan meetings in 2024, and the MDS coordinator acknowledged that Resident #2's care plan was incomplete. These deficiencies in care planning and supervision led to the incident, highlighting the facility's failure to protect residents from neglect and ensure their safety.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their mental and psychosocial needs. One resident, an 84-year-old man with schizoaffective disorder and other conditions, exhibited aggressive behaviors that were not adequately addressed in his care plan. Despite a history of aggressive incidents, including verbal and physical altercations with staff and other residents, his care plan lacked focus areas related to these behaviors. This oversight resulted in multiple incidents where the resident's aggressive actions were not properly managed, culminating in a serious physical altercation that led to his hospitalization with a traumatic brain injury. Another resident, a 92-year-old woman with dementia and other diagnoses, was identified as a fall risk, but her care plan did not reflect this critical information. Despite multiple fall risk evaluations indicating her vulnerability, the care plan failed to include necessary interventions to mitigate this risk. This omission left the resident without appropriate measures to prevent falls, as evidenced by several incidents of unknown origin and other incidents recorded in the facility's logs. Interviews with facility staff revealed systemic issues in care plan management, including a lack of regular updates and communication among the interdisciplinary team. The Unit Manager and MDS staff acknowledged that care plans were not completed or updated in a timely manner, partly due to changes in management and staffing gaps. This lack of coordination and oversight contributed to the facility's failure to provide adequate care and services tailored to the residents' needs, as required by regulatory standards.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to review and revise the person-centered care plan for a resident, leading to a deficiency in care. The resident, an 84-year-old man with schizoaffective disorder, generalized anxiety disorder, and hyperlipidemia, exhibited behavioral issues such as aggression and territorial behavior. Despite these behaviors being documented in progress notes, the care plan did not include any focus areas regarding these behaviors. The resident's BIMS score was 3.0, indicating significant cognitive impairment. The resident's progress notes detailed several incidents of aggressive and territorial behavior, including verbal aggression towards staff and other residents. These incidents were documented over several months, yet the care plan was not updated to address these behaviors. The resident was involved in physical altercations with other residents, resulting in injuries to himself and others. Despite these incidents, the care plan remained unchanged, failing to provide staff with guidance on managing the resident's behaviors. Interviews with facility staff revealed a lack of awareness and action regarding the resident's behavioral issues. The Unit Manager, who was responsible for updating care plans, had not attended care plan meetings in 2024 and was unaware of the resident's behavioral triggers. The MDS coordinator acknowledged that care plans were outdated due to staffing gaps and that the resident's care plan had not been updated following his transfer to a behavioral hospital. This lack of timely updates and communication contributed to the deficiency in care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Branch Transitional Care Center | 0.9 mi | — | 0 | 0 |
| Memorial City Nursing And Rehabilitation Center | 1.2 mi | — | 10 | 2 |
| The Vosswood Nursing Center | 3 mi | — | 0 | 0 |
| The Buckingham | 4.3 mi | — | 0 | 0 |
| Treemont Health Care Center | 4.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.