Avir at Overton

In the surveyor’s words

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

• Immediate jeopardy, patternF600Oct 26, 2023

  Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for Resident Abuse. 1. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 tried to choke Resident #3. 2. The facility failed to protect Resident #21 from abuse by Resident #20. On [DATE] Resident #20 attempted to strike Resident #21 and both fell to floor. 3. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. 4. The facility failed to protect Resident #20 from abuse by Resident #23. […]

• Immediate jeopardy, patternF607Oct 26, 2023

  Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when: 1. On 6/5/23 Resident #20 tried to choke Resident #3. 2 On 6/14/23 Resident #20 attempted to strike Resident #21 and both fell to floor. 3.On 6/14/23 Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. This incident was not investigated or reported. 4.On 6/20/23 Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. […]

• Immediate jeopardy, patternF867Oct 26, 2023

  Based on observation, interview and record review, the facility Quality Assurance and Performance Improvement committee (QAPI) failed to develop and implement appropriate plans of action to correct and identify quality deficiencies for 1 of 1 facility. The facility QAPI failed to identify and implement an action plan to address multiple, resident to resident altercations, that occurred on 6/5/23, 6/14/23, 6/20/23, 8/21/23 and 9/18/23. The facility QAPI failed to identify and implement an action plan to address an elopement that occurred on 6/6/23. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/25/23 at 3:49 PM. […]

• Immediate jeopardy, patternF600Aug 16, 2023

  Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free form neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to ensure Resident #1's care plan was followed, and interventions were in place. The facility failed to ensure Resident #1 received weekly skin assessments The facility failed to ensure the system they had in place with the podiatrist was in functional in providing Resident #1 with the care needed. The facility failed to ensure aides were assessing skin, and feet when providing care. The facility failed to document and assess Resident #1 when concerns were reported from therapy of Residents #1 being in pain and his feet were bleeding. […]

• Immediate jeopardy, patternF687Aug 16, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 of 5 residents reviewed for foot care. (Resident #1) The facility failed to ensure Resident #1 who had diagnosis of diabetes and was at risk for issues with his feet, received assessments, and treatments. The facility failed to ensure accurate, timely skin assessments. Resident #1 had 7 weekly skin assessments from 5/29/23 through 8/7/23 by 7 different nurses and none of those assessments revealed any foot issues. The facility failed to ensure assessments of Resident #1's feet were completed during baths. Resident #1 had bed baths from 8/4/23 through 8/7/23 from 2 different aides. Those aides did not assess his feet during care. […]