Avir at Athens

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free from physical abuse for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse when CNA B slapped Resident #1's arm during patient care on 5/10/26. This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility for 1 of 8 (Resident #1) residents reviewed for abuse. The facility failed to ensure CNA C and LVN D immediately reported an allegation of staff-to-resident abuse on 5/10/26 when CNA B slapped Resident #1's arm to the facility Administrator This failure could place residents at risk of injuries, abuse, and/or neglect.

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the representative immediately of a significant change in condition and transfer to the hospital for 1 of 5 residents reviewed for notification requirements. The facility failed to notify Resident #1's representative on (1/21/2026) when there was a change in the resident's condition requiring the resident to be sent to the local hospital. This failure could place residents at risk of not having family members or representatives notified of changes in condition and allowing them to participate in care decisions. Resident #1 was a [AGE] year-old female born 11/26/1954 and admitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were available and administered for 1 of 6 residents (Resident #87) reviewed for medication administration. The facility failed to ensure that Resident #87's medications Clonazepam (a benzodiazepine medication that produces a calming effect, reducing anxiety) and Hydrocodone-Acetaminophen (an opioid medication that relieves pain) were available for 6 consecutive days following admission. This failure could place residents at an increased risk of and exacerbation of underlying medical conditions, avoidable discomfort, and a decline in physical or psychosocial well-being. A record review of an undated face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 3 of 5 residents (Residents #53, #59, #73) reviewed for medical records accuracy. The facility failed to ensure Resident #53's physician's orders included an order for oxygen use. The facility failed to ensure Resident #59's physician's orders included an order for a foley catheter. The facility failed to ensure resident #73's physician's orders included orders for diet and dialysis treatments. These failures could place residents at risk for errors in care and treatment.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #87) reviewed for care plans. The facility failed to ensure that Resident #87 had a completed baseline care plan within 48 hours of admission. This failure could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and of having personalized plans developed/implemented to address their needs.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate MDS assessments were completed for 6 of 9 residents (Residents #1, #2, #17, #50, #60, and #65) reviewed for accuracy of MDS assessments. The facility failed to ensure Residents #1, #2, #17, #50, #60, and #65's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 of 4 residents (Resident #54) reviewed for change in condition. LVN B failed to notify the physician when she did not administer Resident #54's scheduled insulin dose due to low blood sugar level. This failure could place residents at risk for non-therapeutic effects of the medication and decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3(Resident #22) reviewed for pharmacy services. MA C failed to administer a correct dose of a scheduled medication, lactulose solution (to treat constipation and liver disease) to Resident #22 as ordered by the physician. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications which could result in diminished health and well-being.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a resident had the right to be free from abuse for 1 of 7 residents reviewed for abuse (Resident #1). LVN E and CNA D witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. The facility failures could have caused residents serious physical injury. Findings Included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the alleagtion involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law for 1 of 7 residents reviewed for abuse (Resident #1.) LVN E and CNA D did not immediately report abuse to the Administrator after they witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #2). CNA A failed to ensure two staff members provided a Hoyer lift transfer. A family member assisted with the transfer, the Hoyer lift sling strap was not attached properly, and Resident #2 fell out of the Hoyer lift. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 3/3/24 and ended 3/3/24. The facility had corrected the noncompliance before the survey began. This failure could have caused serious injury.

Inspectors wroteBased on interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 (Resident #74) residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #74 did not receive a medication she was allergic to (ibuprofen) ordered for a swollen right hand on 5/22/23. 2. The facility failed to ensure Resident #74 was not given medications she was allergic to as ordered (ibuprofen 400 mg by mouth 4 times a day for 14 days). Resident #1 received ibuprofen from 05/22/23 to 07/23/23 (63 days). 3. The facility failed to ensure Resident #74's ibuprofen was discontinued after Resident #1 returned from the hospital from an upper GI bleed. Resident #1 received scheduled ibuprofen on 07/26/23 through 07/27/23 (4 doses). An Immediate Jeopardy (IJ) was identified on 10/20/23. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR 1) Screening for 3 of 12 residents reviewed for PASRR (Residents #12, 23, and #45). The facility failed to ensure Residents #12, #23, and #45 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #127). The facility failed to ensure pantoprazole granules DR for oral suspension were administered correctly to Resident #127. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them correctly as directed by manufacturer's directions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to 1 of 2 rooms (DON's office) and 1 of 3 medication carts used for storage of medications and other biological chemicals. The facility failed to ensure MA B kept OTC medications secured in the medication cart and unable to be accessed by unauthorized personnel. The facility failed to ensure the DON's office was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for infection control and based on observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 7 residents (Resident #'s 6, 27, 32, 46, 68 and 70) reviewed for infection control practices, in that:. *Resident #'s 6, 42, and 68's O2 tubing was not covered and Resident #46's oxygen tubing was not labeled correctly. *Resident #70's Nebulizer tubing was not covered. *Resident #32's CPAP tubing was dirty and not covered; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed prior to admission. For 1 of 12 residents (Residents #60) reviewed for PASRR Level I screenings. The facility failed to have a level 1 PASRR assessment for Resident #60 available/documented. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent. There were 3 errors out of 34 opportunities, resulting in an 8 percent medication error rate involving 1 of 3 residents (Resident #13). MA B failed to administer 2 scheduled medications, spironolactone (to treat excess fluid in the tissues) and vitamin D3 (to treat vitamin deficiency), to Resident #13 as ordered by the physician. MA B failed to follow physician's orders regarding specific instructions for the administration of polyethylene glycol 3350 (for treatment of constipation). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in a decline health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents (Resident #13) reviewed for medication administration accuracy. MA B failed to administer a scheduled medication, spironolactone (used to treat high blood pressure and excess fluid in the tissues, to Resident #13 as ordered by the physician. This failure could place the resident at risk of not receiving the therapeutic effects of the mediation and could result in a decline health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 2 of 3 days reviewed for staffing postings (10/22/23 - 10/23/23) and did not maintain the posted daily nurse staffing data for a minimum of 18 months. The facility did not post the required staffing with hours worked daily for the public and residents and did not maintain the staffing for a minimum of 18 months. This failure could place the census of 76 residents, families, and visitors at risk of not having the daily nurse staffing data.