Avir at Golfcrest

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 7 residents (Residents #127, 37 and #97) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #127's dental recommendations on 02/25/2026. 2. Resident #7's care plan did not address her Apixaban to prevent blood clot.3. Resident #97's care plan did not address her Clopidogrel Bisulfate hematological agent.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for four residents (Resident #114, Resident #122, Resident #50 and Resident #1) out of six residents reviewed for ADLs. The facility failed to provide personal hygiene to Resident #114 which resulted in the resident having long fingernails and dark brown substances under the fingernails. The facility failed to provide personal hygiene to Resident #122 which resulted in the resident having facial hair on her chin. The facility failed to provide personal hygiene to Resident #50, which resulted in the resident having long fingernails and dry, flaky, skin from below both knees to his feet. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 8 residents (Residents #57, #71 and #7), 1 of 1 smoking areas, and 2 of 10 rooms (Room B and Room C) observed for accident hazards and environment.1. Resident #57 was observed smoking without supervision on 06/30/2026 and Residents #71 and #7 were observed smoking without supervision on 07/02/2026.2. The smoking area did not have any ashtrays within reach for residents to use.3. Room B's restroom sink's hot water was 115 degrees F on 07/01/2026.4. Room C's restroom sink's hot water was 114 degrees F on 07/01/2026.5. The facility failed to ensure HK Q and Dietary Aide A did not prop open the exit door by the laundry.6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13%, based on 4 errors out of 30 opportunities, which involved 3 of 7 residents (Residents #48, #53, #138, and #149) and 3 of 4 staff (LVN DM, LVN ED, and LVN CO) reviewed for medication errors, in that: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. 1. The facility failed to ensure that serving utensils, bowls, and cups with dried food particles and water stains were not stored with clean utensils, bowls and cups. 2. The facility failed to ensure that clean pots and pans were free of grease and food particles. 3. The facility failed to ensure the floor tiles in the dry storage room were in good repair and the floor was free of dust. 4. The facility failed to ensure that food in the freezer was labeled and dated.5. The facility failed to ensure that kitchen equipment was clean and in good repair.6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents ( Resident #150, Resident #53, Resident #48, Resident #138 and Resident #1) and 7 of 11 staff (LVN ED, LVN CO, LVN BK, HK H, CNA NH, Staffing Coordinator and CNA Y). 1. LVN BK failed to ensure that sterile technique was maintained during Tracheostomy care to Resident #150 on 7/1/26. 2. LVN ED failed to wash or sanitize hands between Resident #53 and Resident #138 on 7/1/26. 3. LVN CO failed to wear PPE when assisting Resident #48 and did not discard PPE in the hazardous box on 7/1/26. Resident #48 had EBP posted on the door. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 4 of 10 resident rooms reviewed for environment. -Room A had a live roach crawling on the ground near the restroom on 06/30/2026.-Room B had a dead brown bug in the restroom on 07/01/2026. -Resident #23 had two flies flying around and landing on a resident's pillow on 07/01/2026.-Room E had an a/c unit on 07/01/2026, 07/02/2026 and 07/03/2026 which was not allowed under facility policy. These failures could place residents at risk for disease and infection and a decline in their physical health due to pests in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 2 of 6 residents (Resident #48 and Resident #98) reviewed for resident rights.1. Resident #48's had a missing hot water faucet handle on 06/30/20262. Resident #98's restroom wall and sink were damaged on 07/01/2026. These failures could place residents at risk of injuries, cross-contamination, avoidable infections and a decrease in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #1) reviewed for incontinent care. The facility failed to ensure Resident #1's Foley catheter bag and tubing was not touching the floor. The facility failed to ensure CNA NH kept Resident #1's Foley catheter bag below Resident #1's bladder level and used appropriate hand hygiene during foley catheter care on 07/01/26., The facility failed to ensure Resident #1 Foley catheter tubing had had Statlock to stabilize the tubing from pulling. The facility failed to ensure CNA H and the Staffing Coordinator used appropriate hand hygiene during foley catheter care for Resident #1 on 07/01/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for 1 of 1 resident (Resident #150) reviewed for respiratory care. -The facility failed to provide tracheal care and suctioning according to professional standards for Resident #150. These deficient practice could result in the residents not receiving the care and services ordered by the physician and a decline in health status and oxygen deprivation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free of any significant medication errors for 1 of 7 residents (Resident #149 ) reviewed for medications. -LVN DM failed to administer medication Effer K (Potassium is a vital mineral and electrolyte that carries an electrical charge, allowing the body to function) to Resident #149 according to Physician's order on 6/30/26. Resident #149 did not consume all of the Effer K medication. The failure could place residents with high or low blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart A) reviewed for medication storage. -Nurse Cart A medication cart had medications that were opened and undated. This failure could place residents at risk of receiving expired medication and improperly stored medications, which could result in delayed healing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared by a method that conserved nutritive value, flavor, and appearance in one of one kitchen. The facility failed to ensure that carrots, green beans, and green peas for lunch were not left on the stove at a low temperature for 3 hours prior to lunch. This resulted in the green beans and carrots being overcooked and unattractive. This failure could place all residents who ate meals prepared by the kitchen at risk of not getting the nutrients needed to prevent malnutrition and weight loss. Findings Included: Observation on 6/30/2026 at 9:05 am of the stove in the kitchen revealed cooked green beans, carrots, ham and whipped sweet potatoes were on the stove cooking for lunch. There were two pans on the grill, one with pureed green beans and one with pureed ham for lunch. The grill was hot. [...]

Inspectors wroteBased 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. This failure has the potential to place residents at risk for serious harm, hospitalization and death.

Inspectors wroteBased 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. This failure placed dependent residents at risk of not receiving proper care, a decline in health, and pain.

Inspectors wroteBased 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. This failure placed residents who experience falls with injury at risk of not receiving adequate treatment in a timely manner, further injury, and pain.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for transfers. Resident #1 was transferred from her motorized wheelchair to the bed with a sit to stand hoyer lift using a sling that was too small to secure around her waist and had a broken buckle. This could place residents who utilize the sit to stand hoyer lift at risk for falls and serious injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 4 (Resident#31, #71, 77 and 82) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident#31's annual MDS assessment 08/02/24 accurately reflected her lack of natural teeth in her oral cavity. The facility failed to ensure Resident#71's annual MDS assessment dated [DATE] accurately reflected his continuous dental problems. The facility failed to ensure Resident#77's annual MDS assessment dated [DATE] accurately reflected her mental illness condition. The facility failed to ensure Resident#82's annual MDS assessment accurately reflected his continuous dental problems. These failures could place residents at risk for receiving inadequate care and services due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10% based on 3 out of 30 opportunities, which involved 3 of 3 residents (Resident #25, Resident #54, and Resident #93) and 2 of 2 staff (LVN and MA A) observed during medication administration reviewed for medication error. 1. The facility failed to ensure that Resident #25's aspirin was administered as ordered as chewable on 3/25/25 at 8:50 a.m. as the aspirin was swallowed whole. 2. The facility failed to ensure that Resident #54's Cholecalciferol Oral Tablet 50 mcg was administered as ordered on 3/25/25 at 9:02 a.m. as D3 125 mcg (5000 IU) was administered. 3. The facility failed to ensure that Resident #93's aspirin was administered as ordered as chewable on 3/25/25 at 8:38 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to refer 1 of 8 residents (Resident #48), reviewed for PASRR screening and evaluations, with a newly evident mental disorder or a related condition for a level II PASRR review. Resident #48 was not referred to the state-designated authority for a PASRR evaluation upon evidence of new diagnoses of bipolar disorder dated 10/16/24 and anxiety disorder dated 10/14/24. These failures placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 12 residents (Resident #1) reviewed for PASARR in that: - Resident #1 did not have a PASARR assessment completed within 20 days of admission. This failure could place newly admitted residents at risk of not receiving services to meet their needs. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 12 residents (Resident #1) reviewed for PASRR assessments. -The facility failed to ensure Resident #1 who had a diagnosis of major depressive disorder, and intellectual disability, had an accurate PASSR Level I assessment or received a PASRR Level II assessment or evaluation. - Resident #1 did not have a PASARR assessment completed within 20 days of admission. This failure could place residents with a serious mental illness at risk of not receiving needed care and services to meet their individual needs. Findings Include: [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident #2) of 12 residents reviewed for abuse and neglect. -The facility failed to ensure that Resident #1 was free from mental abuse when CNA B yelled at him and used a racial slur during his nephrology appointment at the hospital. This failure could place residents at risk of serious harm that has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an assessment which accurately reflected the resident's status for 2 of 24 (Resident #77 #93) residents reviewed, accuracy of assessment in that: The facility failed to assess Resident #77 and Resident #93 for fall on the quarterly MDS assessment after a fall. This failure could place residents at risk of not having accurate assessments, which could compromise their plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 5 (Resident #29, Resident #44, Resident #115, Resident #86, and Resident #122) out of 25 residents reviewed for care plan accuracy. - The facility failed to care plan Resident #29's fall from 11/14/23. The facility also failed to remove the Restorative Program from her care plan when she was no longer on the program. - The facility failed to care plan Resident #44's fall from 9/2/23. The facility also failed to care plan Resident #44's ST he was receiving. - The facility failed to remove the pressure ulcer to the left lower leg of Resident # 115's care plan. The facility also failed to care plan Resident # 115's OT he was receiving, his code status, and the oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 7 residents (anonymous residents) reviewed for food palatability. The facility failed to provide residents meals that was at an appetizing and correct temperature. There failures could cause residents to not eat their food, and which could affect their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 2 of 3 medication storage rooms (medication storage room [ROOM NUMBER] and medication storage room [ROOM NUMBER]) reviewed for physical environment, in that: - The facility failed to remove expired blood collection tubes, Tuberculin syringes, inner cannulas for trachs and trachs with inner cannulas, wound dressing kits, IV start kits, viral transport for viruses, and trach adapters with drainage bags from the medication storage room on Nursing Station 3. - The facility failed to remove expired blood collection tubes, IV tubing, a leg bag, IV bags, and IV regulator sets from the medication storage room on Nursing Station 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 out of 1 kitchen as evidence by: Roaches were observed dead in the kitchen, and some were observed crawling in the kitchen area. These failures could place all residents in the facility at risk of infection and a decline in their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 2 (Resident #38, #77,) of 24 residents reviewed for comprehensive assessment. 1. The facility failed to accurately assess Resident #38 for her oral cavity. 2. Resident #77's dental information was not addressed. These failures could place the residents at risk of not having all medical needs assessed and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 25 residents (Resident #122, and Resident #115) reviewed for comprehensive care plans. - The facility failed to care plan PTSD for Resident #122 when he was admitted with it. The facility also failed to care plan his assistance with ADLs. - The facility failed to care plan PTSD for Resident #115. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 (Nursing Station 3) medication storage rooms reviewed for medication storage in that: - The facility failed to keep food out of the refrigerator used only for medication, in the medication storage room on Nursing Station 3. This failure could place residents at risk for infection, and/or worsening health concerns.