Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Keeneland during CMS and state inspections, most recent first.
Kitchen sanitation, food storage, and equipment cleaning failures: The kitchen floors were observed dirty with food particles, dried residue, and grease; a refrigerator shelf was soiled with a sticky substance and utensils were found underneath it; and a second refrigerator contained an uncovered, unlabeled, undated food item plus potato salad containers without open or expiration dates. The fryer was coated with grease and food crumbs, the surrounding floor had food debris and greasy buildup, and a chocolate syrup container was stored without refrigeration despite the manufacturer label requiring it after opening. The DM, DON, and ADMN stated kitchen cleaning, labeling, and storage were the responsibility of kitchen leadership and staff.
Controlled substance records were not properly reconciled for three residents. A pregabalin count did not match the blister card, hydrocodone/acetaminophen counts were inconsistent between the log and the lock box, and lorazepam topical rub counts in the refrigerator did not match the narcotic log. Nursing staff also failed to sign controlled count sheets at shift change and did not document administered meds promptly, while the ADON and DON stated counts and signatures were expected to be completed appropriately.
Incomplete Consent for Psychoactive Medications: A resident with dementia, bipolar disorder, schizoaffective disorder, depression, anxiety, and insomnia had multiple psychoactive meds ordered, including Trazodone, Alprazolam, Effexor XR, and Depakote, but the consent forms were incomplete or lacked signatures and required details such as risks, benefits, duration, and the name/date of the person obtaining consent. The RNC stated the forms had been started during EHR audits and were intended to be completed by facility nurses, while the DON stated consent was expected before the initial dose of a psychoactive medication was given.
Incomplete Annual MDS Assessment: A resident with vascular dementia, HTN, depression, anxiety, a pacemaker, and atherosclerotic heart disease did not receive a completed annual MDS, and the most recent quarterly MDS was also overdue. The RNC stated the assessment had fallen through the cracks and had not been followed up on, despite the facility policy and CMS RAI requirements for timely completion and transmission of MDS assessments.
Medication storage and labeling were not maintained properly in 1 medication room and 1 medication cart. Surveyors found loose pills in the South Hall med cart drawer and 3 sealed bottles of sodium bicarbonate in the med room with an expired date. The LVN-C said it was her first day in training and she had not checked the cart as she should have, while the ADON and DON described expectations for keeping carts tidy and removing expired meds.
A resident with multiple complex medical conditions and a high risk for pressure ulcers did not have weekly skin assessments documented as required by facility policy. Nursing staff and the DON confirmed that these assessments were the responsibility of charge nurses and should have been recorded in the clinical software, but documentation was missing for two weeks.
Two residents in the facility experienced deficiencies in tube feeding management. A resident with severe cognitive impairment had unlabeled feeding bags and improper head elevation during feeding. Another resident's feeding setup was also unlabeled and not connected when observed. The DON and ADON attributed these issues to an educational gap among nursing staff.
The facility failed to maintain an effective infection control program during wound care for two residents. A resident with severe cognitive impairment received care with unclean shears, and another resident's wound was contaminated by placing her hand on her gown without a barrier. The DON acknowledged these actions as cross contamination, contrary to facility policy.
The facility failed to ensure the Dietary Manager (DM) met the certification requirements, as the DM did not have a Dietary Manager Certificate despite being in the role for two years. The DM confirmed the lack of certification and planned to start online classes. The Administrator expected the DM to have completed a food service manager's course and hold certification. This deficiency could risk residents' nutritional needs and increase the risk of foodborne illnesses.
Kitchen sanitation, food storage, and equipment cleaning failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation of the kitchen, the floors were found dirty with food particles, a white dried flaky substance, and a greasy film. The first commercial refrigerator had a soiled bottom shelf with a brown sticky substance, and two forks were found underneath the refrigerator. The third commercial refrigerator contained a cup of purple gel substance that was open to the air with no cover, label, or date, and also contained two large white plastic containers labeled as potato salad without an open date or expiration date. The fryer was observed covered on all sides with grease, with fried food crumbs in the oil and on the fryer surfaces. The floor around the fryer and next to the stove had dried orange food particles and other brown greasy substances. A spice rack contained a large brown container of chocolate syrup that had been opened on 02/25/2026, and the manufacturer label stated it should be refrigerated after opening. On follow-up observation, the fork remained underneath the first refrigerator and dried greasy substances were still present under and around the fryer. In interview, the Dietary Aide stated cleaning responsibilities were shared by all kitchen staff and that each shift was responsible for sweeping and mopping floors at the end of the shift. The Dietary Aide also stated the fryer oil was changed weekly and the fryer was thoroughly cleaned after fish was cooked on Fridays. The DM stated she had recently fired an entire shift for not completing tasks and that the remaining staff were trying to catch up on deep cleaning. She stated she was responsible for ensuring staff cleaned per policy and schedules, and she was not sure when the Jello or potato salad had been placed or opened, then discarded them. She also stated she was not aware the chocolate syrup required refrigeration and discarded it. The DON and ADMN stated the DM was responsible for keeping the kitchen clean and in order, and both identified foodborne illness and sanitary issues as possible negative outcomes.
Controlled Substance Counts and Documentation Not Reconciled
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for three residents reviewed for pharmacy services. During observation, interview, and record review, the controlled count reconciliation sign-off sheet for the south hall was not signed at shift change by both the oncoming and off-going nursing staff. The facility also failed to accurately and timely complete documentation of controlled drug administration for Resident #13, Resident #20, and Resident #30. For Resident #20, the pharmacy blister card for pregabalin contained 24 capsules while the controlled substance count sheet reflected 25 available, and the LVN stated the medication had been administered but had not yet been signed out. For Resident #30, the hydrocodone/acetaminophen count sheet reflected 72 available while the blister pack in the narcotic lock box showed 73, and the LVN stated she had voided the entry and asked another nurse to co-sign. For Resident #13, the lorazepam topical rub log sheet reflected 7 available while the narcotic lock box in the refrigerator contained 4 syringes, and the LVN later signed the narcotic sheet late and stated the refrigerator medications had not been counted. The ADON and DON stated that controlled substance counts and documentation were expected to be completed and signed appropriately.
Incomplete Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure Resident #3 had a signed consent form for several psychoactive medications that were ordered by the physician, including Trazodone, Alprazolam, Effexor, and Depakote. The resident’s record showed diagnoses of dementia, Parkinsonism, bipolar disorder, schizoaffective disorder, major depressive disorder, anxiety, and insomnia. The resident’s current order summary listed Trazodone 50 mg by mouth in the evening for recurrent major depressive disorder, Alprazolam 0.5 mg by mouth three times a day for anxiety, Effexor XR 150 mg and 75 mg at bedtime for recurrent major depressive disorder, and Depakote Sprinkles 250 mg daily for bipolar disorder. The psychoactive medication consent forms in the record were incomplete. The form for Trazodone did not document the beneficial effects expected, potential risks and side effects, proposed duration, consent and education, type of consent obtained, or the name and date of the person obtaining permission and the resident, guardian, or legal representative who consented. The Alprazolam form was also incomplete and lacked the potential risks and side effects, proposed duration, consent and education, type of consent obtained, and identifying information for the person obtaining permission and the person consenting. The Effexor 75 mg form documented verbal consent, but did not include the name and date of the person obtaining permission or the resident, guardian, or legal representative who consented. The Effexor 150 mg form lacked the condition to be treated, beneficial effects expected, potential risks and side effects, proposed duration, consent and education, type of consent obtained, and identifying information for the person obtaining permission and the person consenting. The Depakote form documented improved functional ability as the expected benefit, but did not include the potential risks and side effects, proposed duration, consent and education, type of consent obtained, or identifying information for the person obtaining permission and the person consenting. The resident’s MDS assessments documented severely impaired decision-making skills, memory problems, and diagnoses including non-Alzheimer’s dementia, anxiety, depression, bipolar disorder, and schizophrenia. The quarterly MDS also noted depressed mood indicators, appetite change, trouble concentrating, and slow speech/movements. During interview, the RNC stated the Corporate MDS Coordinator had started the psychoactive medication consent forms during electronic health record audits and intended for facility nurses to complete them and obtain consent from the resident’s responsible family member or representative. The DON stated the expectation was to obtain consent before the initial dose of a psychoactive medication was administered and stated consent was needed for Depakote when used for mood stabilization. The facility policy stated residents and/or representatives are involved in psychotropic medication management and have the right to decline treatment, with staff and the physician reviewing risks and alternatives with the resident/representative.
Incomplete Annual MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident #13 received a comprehensive annual MDS assessment in a timely manner. Record review showed the resident was admitted on 02/10/2025 and readmitted on 08/01/2025, with diagnoses including vascular dementia with agitation, hypertension, depression, anxiety, a cardiac pacemaker, and atherosclerotic heart disease. On 03/19/2026, the resident’s electronic MDS record showed the Annual MDS was still in progress and not completed, making it 36 days overdue at 402 days. The most recent Quarterly MDS had been accepted on 11/11/2025, and the next quarterly assessment was also 36 days overdue at 128 days. During interview, the RNC stated she needed to call the remote MDS nurse because the new ADON nurse in training would be taking over the MDS process soon. Later that day, the RNC stated the MDS for Resident #13 had “fallen through the cracks” and had not been followed up on. She stated it was her expectation that all MDS assessments be completed and transmitted in a timely manner according to policy and regulations, and that the DON would ultimately be responsible for the accuracy and timely reporting of the MDS. The facility policy required the resident assessment coordinator to ensure timely and appropriate resident assessments, and the CMS RAI User’s Manual stated the annual assessment must be completed on an annual basis and within the required timing parameters.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in 1 of 1 medication rooms reviewed and 1 of 2 medication carts reviewed. During an observation of the South Hall medication cart, several loose pills were found in the second drawer. An LVN-C stated it was her first day in training and that she had not looked through the cart as she should have; she then removed the loose medications and placed them in the sharps box on the side of the cart. During an observation of the medication room, several bottles of medication were seen on a shelf, including 3 sealed bottles of sodium bicarbonate 325 mg tablets with 100 tablets each. The expiration date on each bottle was 10-25. The ADON stated she expected the nurse administering medications to keep the cart tidy and free from loose medications, and that expired medications in the medication room should be destroyed properly. She also stated it was her responsibility to order and check stock in the medication room, but she had not yet been able to complete that task. The DON stated she expected nurses to keep medication carts cleaned and free from spills and loose pills in the bottom of the drawers.
Failure to Document Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically by not documenting weekly skin assessments as required. Record reviews showed that a female resident with multiple diagnoses, including cerebral palsy, stroke, vascular dementia, diabetes, schizophrenia, and muscle wasting, was at risk for pressure ulcers according to her care plan and MDS assessment. The care plan directed weekly skin assessments and documentation, but there was no evidence that these assessments were performed or recorded on two specific weeks. Interviews with nursing staff and the DON confirmed that charge nurses were responsible for conducting and documenting weekly skin assessments, and that the facility's electronic system highlighted when assessments were due. Staff acknowledged that the assessments may have been performed but were not documented in the resident's chart. The facility's policy required weekly skin assessments to be documented in the clinical software, but this was not done for the identified periods.
Deficiencies in Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of tube feeding for two residents, leading to deficiencies in care. Resident #8, a female with severe cognitive impairment and dysphagia following a stroke, was observed with her tube feeding formula and water not properly labeled. Additionally, her head of bed was not elevated to the required 30 degrees while her tube feeding was infusing, which is against the physician's orders and facility policy. Resident #23, a male with a history of stroke and dysphagia, also had issues with tube feeding management. His tube feeding formula and water bags were found without labels indicating the date prepared or resident information. This was observed when the resident was not in the room, and the feeding setup was hanging but not connected to him. The facility's policy requires that all feeding bags be labeled with specific information, which was not adhered to in this case. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that these issues were attributed to an educational gap among the nursing staff, particularly with newly hired nurses. The DON acknowledged that the head of the bed should be elevated during and after tube feeding, and that all feeding bags should be properly labeled. The facility's policy on enteral feeding administration was not followed, leading to these deficiencies.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper wound care provided to two residents. Resident #26, a female with severe cognitive impairment and a stage 3 pressure ulcer, received wound care where the DON used shears that were not cleaned prior to use. This action was contrary to the facility's infection control policy, which requires reusable items to be cleaned and disinfected between residents. The DON acknowledged that the shears had been out of his sight and could not guarantee they were clean, recognizing the potential for cross contamination. Similarly, Resident #32, who had a pressure injury and was unable to communicate effectively, was subjected to wound care where her hand was placed on her gown without a barrier after cleansing. The DON admitted that normally someone would hold the resident's hand to prevent contamination, but this was not done as the resident was not in pain. The DON recognized this as cross contamination. These actions demonstrate a failure to adhere to infection control policies, potentially placing residents at risk for infection.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to conduct the functions of the food and nutrition service. Specifically, the Dietary Manager (DM) did not meet the requirements for a certified dietary manager. A review of the DM's employee file revealed a hire date of January 20, 2021, but no documented evidence of a Dietary Manager Certificate was found. In an interview, the DM confirmed she did not have her dietary manager certification and had been working in the role for two years after starting in Housekeeping. She mentioned plans to start online classes after the New Year and held a current food handlers' certificate. The facility's Administrator stated the expectation that the DM should have completed a food service manager's course and hold a current certification as a Dietary Manager. The job description for the Dietary Manager included managing the operations of the dietary department, which requires successful completion of the Certified Dietary Manager exam. The lack of certification could place residents at risk of not having their nutritional needs met and increase the risk of foodborne illnesses.
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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 Weatherford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peach Tree Place | 0.9 mi | ★★★★★ | 1 | 0 |
| College Park Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Avir At Weatherford | 1.9 mi | ★★★★★ | 12 | 2 |
| Santa Fe Health & Rehabilitation Center | 2 mi | ★★★★★ | 11 | 0 |
| Holland Lake Rehabilitation And Wellness Center | 2.2 mi | ★★★★★ | 8 | 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.