Avir at San Knoll

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 14, 2024

  Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF689May 7, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed accidents and hazards in that: The facility failed to ensure Resident #1 did not elope after he was identified to be of high risk for elopement. Resident #1 eloped on 5/3/23 around 9:00 a.m. and was found on 5/4/23 around 6:47 p.m. The facility failed to implement measures to prevent future elopements. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/5/23 at 6:06 p.m. […]

• No harm, potential for more than minimal, patternF584Jul 24, 2026

  Based on observation, interview, and record review the facility failed to provide a comfortable and homelike environment including comfortable and safe temperature levels for 1 of 2 dining rooms (main dining hall). The facility failed to ensure the temperature in the main dining room was not above 81 degrees on 6/25/26, 7/21/26, and 7/24/26;The facility was not consistently monitoring the temperature in the dining room;The facility did not complete air conditioning repairs to ensure the unit was cooling properlyThis failure could place any residents at risk of living in an unsafe environment and result in feelings of dissatisfaction. […]

• No harm, potential for more than minimal, patternF584Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to clean towels for showers for 4 of 4 (Resident #1, Resident #9, Resident #10 and Resident #12) reviewed for available linen. The facility failed to ensure Resident #9, Resident #10, and Resident #12 had clean towels available to them to shower.This failure could lead to residents feeling neglected, infection control concerns, and emotional well-being.The findings include:Record review of Resident #1's admission Record, dated 04/22/2026, revealed a [AGE] year-old-male that admitted on [DATE] with diagnoses that included Morbid Obesity (a chronic, complex disease defined by a body mass index of 40 or… […]

• No harm, potential for more than minimal, patternF677Apr 24, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 4 residents (Resident #1, Resident #9, Resident #10, Resident #12) reviewed for ADL care.The facility failed to ensure that Resident #1, Resident #9, Resident #10, and Resident #12 regularly obtained showers, per resident rights. […]