Avir at The Meadow

In the surveyor’s words

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

• Immediate jeopardy, patternF697Dec 1, 2023

  Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #36) of 8 residents reviewed for pain management. The facility failed to ensure Resident #36 received her scheduled pain medication every six hours as ordered when her supply ran out. Resident #36 received no scheduled or PRN pain medication for more than two days until surveyor inquiry causing her to experience severe pain. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. […]

• Immediate jeopardy, patternF755Dec 1, 2023

  Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #36) of 8 residents reviewed for pharmacy services. 1. The facility failed to obtain the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication causing her to experience severe pain. The medications were received after surveyor inquiry. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. […]

• Immediate jeopardy, patternF760Dec 1, 2023

  Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for one (Resident #36) of 8 residents reviewed for pharmacy services . The facility failed to administer the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems. […]

• Immediate jeopardy, isolatedF689Jul 2, 2021

  Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices for one (Resident #65) of six residents reviewed for accidents and incidents. The facility failed to implement monitoring, supervision, and interventions for Resident #65, who had a known history of illegal substance abuse and was HIV positive. An Immediate Jeapordy (IJ) situation was identified on 07/01/21 at 4:10 PM. While the IJ was removed on 07/02/21, the facility remained out of compliance at a scope of a pattern with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injury and/or death from drug-related harm, including overdose. […]

• Actual harm, isolatedF583Dec 6, 2024

  Based on interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy. 1. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. […]