Avir at Borger

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 8, 2023

  Based on interviews, observations, and record reviews, the facility failed to ensure that the residents are free from accidents and hazards for 1 (Resident #1) of 5 residents reviewed for mechanical lift transfers. LVN A failed to prevent accidents and hazards with Resident #1 from injury and harm by not following mechanical lift standards of a two person assist resulting in severe injuries of a 10+ centimeter laceration on the head revealing skull, a laceration on the hand, and a fractured C1 vertebrae. This failure could affect residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and death. An Immediate Jeopardy (IJ) was identified on 11/07/2023 at 2:43 PM. […]

• Immediate jeopardy, isolatedF760Apr 15, 2022

  Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 of 5 residents (Resident # 1) reviewed for medications. The facility failed to ensure Resident #1's hospital discharge medication orders were followed for insulin from his admitted [DATE] until he was found unresponsive and sent to the hospital on [DATE]. Resident #1 was not administered his scheduled insulin at night for 3 nights nor did he receive his insulin per sliding scale three times a day, missing 8 total doses. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 4:30 PM as having occurred from [DATE] - [DATE]. […]

• Actual harm, patternF697Sep 12, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #14) of 12 residents reviewed for pain management.The facility failed to ensure Resident #14 did not have mouth pain from at least March of 2025 to August of 2025.This failure could place residents at risk of living for extended periods of time with unaddressed pain. […]

• Actual harm, isolatedF689Mar 17, 2022

  Based on interviews and record review, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers. LVN A failed to hold the smoke room door open when Resident #1 had two fingers on his left hand squashed between a door jam and the door resulting in a trip to the emergency room and receiving 19 stitches and multiple fractures. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, suffocation, subdural hematomas, and death. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2025

  Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.The facility failed to ensure stored food was properly labelled and dated.The facility failed to ensure dented cans were placed in the specified area to be returned.The facility failed to discard leftover food by use by date on the label.The facility failed to ensure the floor, walls, trashcan, and bathroom of the kitchen were clean and sanitized.The facility failed to ensure food was stored at least 6 inches off the floor.These failures could place residents at risk of food borne illness.Findings included:An observation on 08/25/25 at 05:35 AM revealed a meal… […]