Avir at Weston

In the surveyor’s words

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

• Immediate jeopardy, patternF686Feb 12, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident # 1 and Resident #9) of 5 Residents reviewed for pressure ulcers. 1. The facility failed to perform wound care to Resident #9's Stage 3 pressure ulcer to right buttock, as ordered, on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/14/25, 01/20/25, 1/21/25 and 1/22/25 . Resident #9's wound was infected on 01/16/2025 and got worse from a stage 3 to a stage 4. 2. The facility failed to perform wound care on Resident #9's sacral wound per orders for Resident #9 dated 1/16/2025 until 1/23/2025. […]

• Immediate jeopardy, patternF697Feb 12, 2025

  Based on 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 one (Resident #5) of six residents reviewed for pain. The facility failed to provide effective pain management for Resident #5 while she resided at the facility from 01/17/25 - 01/27/25. She had a recently acquired amputation that caused her to be in excruciating pain. The facility did not adjust her pain medication or notify her NP. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/29/25 at 4:04 PM and an IJ template was given. […]

• Immediate jeopardy, isolatedF689Jul 23, 2025

  Based on observation, record review and interviews, the facility failed to ensure resident received adequate supervision to prevent accidents for 3 (Residents 1, 2, and 3) of 6 residents reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on March 26, 2022, February 1, 2025, and again on June 21, 2025. On June 21, 2025, resident #1 was seen on the corner of the facility near a stop sign of an unbusy street. The facility was unsure how the resident eloped. A root cause analysis was not completed to determine how the resident eloped. There were two other residents at the facility (Resident #2 and #3) who were at a high risk for elopement with no interventions to prevent the elopement. […]

• Immediate jeopardy, isolatedF760Jun 13, 2025

  Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #66) of 1 resident reviewed for significant medication errors. The facility failed to ensure Resident #66 received the prescribed anti-convulsant medication on 6/9/2025 and 6/10/2025. Resident #66 had seizure-like activity, was transferred to the ED, and remained admitted at the hospital for diagnosis of seizure. An Immediate Jeopardy (IJ) situation was identified on 6/12/2025. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF600Jun 14, 2023

  Based on observation, interview, and record review the facility failed to ensure residents were free from Neglect for 1of 5 residents (Resident #1) reviewed. The facility failed to ensure that Resident # 1's G Tube and JP drains were cleaned and flushed according to physician's orders, causing the G tube and JP drains not to function properly. The facility failed to ensure Resident # 1 who had a G tube and JP drains received appropriate care and treatment timely. The tubes and drain were found to be dirty and clogged with mold, gnats, flies, maggots, and fly larvae. […]