Avira Health Pavilion

In the surveyor’s words

From the most serious findings on record at Avira Health Pavilion, in the surveyor’s own words.

• Actual harm, isolatedF697Aug 3, 2023

  Based on observation, interview and record review, the facility failed to ensure a resident's pain level was controlled. This resulted in the resident experiencing severe pain. This applies to 1 of 2 residents (R138) reviewed for pain in the sample of 17. The findings include: R138's Admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes right knee joint replacement surgery, depression, and anxiety. On 8/01/23 at 2:34 PM, R138 was in his room with the ice water pump attached to his right knee. R138 had periods of facial grimacing when he moved his leg. On 8/01/23 at 2:34 PM, R138 said, he just had a right knee replacement and he is in severe pain. R138 said, the only thing the nursing staff will give him is Acetaminophen. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2025

  Based on observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items; and failed to ensure the sanitizing solution was at the recommended level. This failure has the potential to affect all 29 residents currently residing in facility.Findings include:On 07/22/2025, upon entering facility, V1 (Administrator) indicated resident in-house census of 29. Facility provided a completed CMS 802 form that indicated resident census of 29.On 07/22/2025 at 10:40 AM, initiated kitchen tour with V4 (Food Service Director) with the following observations. At 10:51 AM, red sanitation bucket near the three compartment sink was tested by V4 (Food Service Director) and test strip read 150 ppm (parts per million). […]

• No harm, potential for more than minimal, widespreadF680Apr 3, 2025

  Based on observation, interview, and record review the facility failed to have a full time Activity Director. This applies to all 32 residents in the facility. The findings include: The Facility census sheet dated 03/30/2025 at 11:59PM, shows, 32 residents in the facility. On 03/31/2025 at 11:25AM, V1 Administrator said, We do not have an Activity Director. On 03/31/2025 at 2:00PM, V2 DON-Director of Nursing said, We do not have an activity calendar for March (2025). The facility's Activity Programs policy revised June 2018 shows, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. […]

• No harm, potential for more than minimal, widespreadF908Sep 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure the walk in freezer was repaired and in safe working condition. This failure has the potential to affect all 24 residents residing in the facility. The findings include: The CMS-671 form completed by the facility on 9/9/24, shows there are 24 residents residing in the facility. During the kitchen tour on 9/9/24 at 9:10 AM, thick frost was noted on the packages of food in the walk in freezer and frozen water was pooled on a box of cookies and a box of diced turkey on the shelf below the fans. A large puddle of water was on the floor between the walk in freezer and the walk in cooler coming from water dripping from the connecting door. […]

• No harm, potential for more than minimal, widespreadF880Aug 3, 2023

  Based on observation, interview and record review the facility failed to ensure droplet precautions were maintained for residents positive with covid-19 by not keeping doors shut on rooms that were safe to have them shut and ensuring staff wore eye protection when entering a covid-19 positive residents' room. This has the potential to affect all the residents in the facility. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents dated August 2, 2023, showed 29 residents reside in the facility. 1. On 8/1/23 at 9:50 AM, R12 was sitting up on the side of his bed with his tray table in front of him. R12 had a cup of medication on his tray table next to his untouched breakfast. […]