Avir at Golfcrest

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (CR #1) reviewed for witnessed falls. The facility failed to ensure 2 staff members remained at bedside on [DATE] during ADL /linen change for CR #1, which resulted in a witnessed fall with major head injury (hematoma [a collection of blood trapped under the skin or inside the body after an injury or damaged blood vessel]), which resulted in hospitalization. CR #1 expired in the hospital on [DATE]. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility corrected the non-compliance before the investigation began. […]

• Immediate jeopardy, isolatedF580Aug 5, 2025

  Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was an accident involving the resident which resulted in injury and required physician intervention for 1 (Resident #1) of 4 residents reviewed for notification of changes. LVN-A failed to notify Resident #1's physician for 24 hours when she complained of pain after a witnessed fall on 06-23-25 which resulted in an acute fracture of the left humerus (the long bone in the upper arm) and soft tissue swelling. The noncompliance was identified as Past Non-Compliance IJ. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF684Aug 5, 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 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure LVN-A adequately assessed, monitored, provided appropriate interventions, and contact the physician immediately when Resident #1 complained of pain after a fall which resulted in an acute fracture of her left humerus (the long bone in the upper arm). The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF695Jul 23, 2025

  Based on interview and record review the facility failed ensure that residents requiring respiratory care are provided with necessary services consistent with their care plans for one of three residents reviewed for the use of oxygen. The facility failed to ensure that CR #1's portable oxygen was fully charged before leaving the facility for a clinic appointment. This failure could place residents at risk of not receiving needed services in an emergency. The noncompliance was identified as PNC IJ began on 0328/25 and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of being neglected by not providing necessary care and services. […]

• Immediate jeopardy, isolatedF740Feb 18, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for one (Resident#122) of 24 sampled residents reviewed for behavioral heath. The facility failed to ensure that Resident #122 had individualized behavioral health needs addressed through a person-centered care plan. The facility failed to ensure that Resident #122's suicidal ideation was addressed and followed up on. An Immediate Jeopardy (IJ) was identified on 02/16/24 at 6:30 PM. […]