Avir at Jeffrey Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 11, 2025

  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 3 residents (Resident #2).On 5/30/2025 at approx. 12:00 p.m., CNA D had been providing incontinent care to Resident #2. While care was being provided, the resident rolled off the bed onto the floor, hitting his face on the nightstand. Resident #2 sustained swelling and redness to the right side of his face, redness to his right knee, and required admission to the hospital on 5/30/25, for further treatment. A review of the care plan dated 5/20/20 reflected that Resident #2 required one-person assistance for bed mobility and transfers. […]

• Immediate jeopardy, isolatedF689Apr 8, 2024

  Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for Resident #1 of 7 residents reviewed for accidents and supervision. The facility failed to ensure Resident # 1 was free from accidents. Resident # 1 eloped from facility on 3/16/2024. Resident # 1 was located two blocks from that facility at a local convenient store that was on busy high traffic road. Resident #1 was found walking in the opposite direction of the facility, disoriented, and confused when facility RN A located her. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/5/202 at 11:30am. The IJ Immediate Jeopardy template was provided to the ADM on 4/5/2024 at 11:30am. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure staff did not use bare or gloved hands when serving food. B. Ensure stored food was properly labeled, dated and stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation of the facility freezer on 2/4/25 at 8:45 am, revealed: a box of frozen cookie dough, open to air and crumbs in the bottom of the freezer. An observation of the facility cooler on 2/4/25 at 8:46 am, revealed: a box of chopped pecans, open to air and an opened package of turkey lunchmeat dated 1/30/25 and a use by date of 2/1/25. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure food items in the dry food storage and refrigerator were dated, labeled, and sealed. 2. The facility failed to provide supplies for adequate handwashing when entering the kitchen area. This failure could place the residents at risk for food borne illness and cross contamination. Findings include: An Observation on 5/4/2023 at 07:30 am revealed there were no towels available at the handwashing sink. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based on observation, interview and record review the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure food safety by not labeling & dating food correctly, wearing hair restraints, and sanitizing equipment during food service. These failures could place residents at risk for foodborne illnesses.Findings include: Observation in the standalone refrigerator on 04/07/2026 at 8:40 AM revealed the following: Cheese in the Ziplock bag had no open date or use-by date on the bag. Lunch meat in a sealed container had the date 4-3 with no use-by date. […]