Avir at Commons

In the surveyor’s words

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

• Immediate jeopardy, patternF610Feb 13, 2026

  Based on observation, interview and record review, the facility failed to ensure they took steps to prevent further potential abuse or neglect while the investigation was in progress and they took appropriate corrective action after the alleged violation was verified for all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. 1. The facility failed to correct identified neglect identified in grievances filed on 02/02/26 related to Resident #1, Resident #3, and Resident #4 extra dummy call lights. 2. […]

• Immediate jeopardy, patternF580Aug 15, 2025

  Based on observation, interview, and record review, the facility failed to immediately consult with the physician when a need to alter treatment significantly due to adverse consequences for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds.On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #1 went to the hospital on 8/11/25 with a diagnosis of groin infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. […]

• Immediate jeopardy, patternF684Aug 15, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds. On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. […]

• Immediate jeopardy, isolatedF697Jul 14, 2023

  Based on interview, observation and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 reviewed for pain. The facility failed to contact the physician in a timely manner regarding Resident #1's pain medication. The facility failed to provide Resident #1 with pain medication for 20 hours after admitting with pain at a 9 out of 10 (0 being no pain at all and 10 being the worst pain you have ever experienced). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/13/23 at 11:40 a.m. […]

• Immediate jeopardy, isolatedF684Sep 10, 2021

  Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 2 of 3 resident reviewed for quality of care. (Resident #1 and Resident #2) The facility failed to ensure Resident #1 and #2 were thoroughly assessed over a period of 3 days. RN A did not obtain vital signs during assessment of Resident #1 and #2 four times each over a course of three days;she documented vital from the previous day. The facility failed to consult Resident #1's physician and document a change in his condition when he vomited. Resident #1 and Resident #2 died on the same day at the facility, approximately 5 hours apart, after not receiving thorough assessments. […]