Avir at Enchanted Rock

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 19, 2025

  Based on interviews, observations, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 26 residents (Resident #1, #2, and #3) reviewed for accidents and hazards supervision, in that: 1. Resident #1 was found in in another town about an hour's drive from the facility. 2. Resident #2 was spotted going down looking (sic) at cars outside of the facility and had not been supervised the whole time she was outside of the facility. There were no assessments (to include skin assessments) done for Resident #2. 3. Resident #3 eloped and was found walking down the street. […]

• Immediate jeopardy, isolatedF689May 2, 2026

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #44) reviewed for supervision. The facility failed to prevent Resident #44 from going out a window without staff awareness. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of other resident elopements and harm the resident with injury or death. […]

• Immediate jeopardy, isolatedF607Jan 13, 2024

  Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: The facility failed to implement their policy to report and investigate Resident #21's 11/21/23 fall with a serious injury, per [state agency] guideline. The Administrator, DON, and LVN D did not report Resident #21's fall with a fracture to the state agency. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. […]

• Immediate jeopardy, isolatedF610Jan 13, 2024

  Based on nterview and record review the facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #21 had an unwitnessed fall with a serious injury on 11/21/23, per [state agency] guideline. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions. […]

• Immediate jeopardy, isolatedF689Jan 13, 2024

  Based on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of residents, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 24 residents (Resident #21) reviewed for quality of care, in that: The facility failed to ensure Resident #21 received appropriate assessments and interventions due to being at high risk for falls. The facility failed to develop Resident #21's care plan to address interventions for risk of falls. Resident #21 had a fall on 11/21/2023 which resulted in an emergency hospitalization for a hip fracture and was admitted to the facility without any interventions for Resident #21's high fall risk. […]