Avir At Golfcrest
Avir at Golfcrest in Houston, TX — inspection on May 23, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Survey on 16 residents who were at risk of falling, and residents needing two-person assistance on [DATE] and [DATE] respectfully.
Record review of CNA L's personnel file on [DATE] revealed CNA L was suspended on [DATE] and was terminated on [DATE].
During an interview with Resident #5 on [DATE] at 10:56 a.m. Resident #5 stated that she always has two staff members that always assist her with ADLs, repositioning, and transfers because she cannot do it by herself.
During interviews on 05/ 21/2026 between 10:27 a.m. through 3:33 p.m., ADON, LVN A, LVN B, LVN C, RN G, RN H, CNA J, CNA K, CNA L, CNA M, and on [DATE] between 12:58 p.m., through 2:53 p.m., LVN D, LVN E, LVN F, RN T, RN U, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, were able to state that they were aware of the fall incident involving CR #1 who was care planned for two - person assistance, but one staff provided the care on [DATE], which resulted in CR #1's fall with injury.
They stated that if only one staff member attempted to assist a resident requiring a two-person assistance, the resident would be at risk for falls and possible injury.
They stated that they had been reeducated regarding the facility's fall prevention interventions.
They stated that they had received in-service education related to fall risk residents, abuse, neglect, care plan review prior to resident's care, Kardex, two -person assistance with ADLs, fall prevention using the acronym CHIPS.
Observations of two-person in-bed peri-care of Resident #4 on [DATE] at 2:30 p.m., showed no concern, and staff followed appropriate steps to ensure care and resident safety.
Observations of two-person in-bed peri-care of Resident #6 on [DATE] at 2:45 p.m., showed no concern, and staff followed appropriate steps to ensure care and resident safety.
Record review of facility's policy on Assessing Falls and their Causes with revision date on [DATE] revealed in parts .
The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.
Preparation: 1.
Review the resident care plan to assess for any special needs of the residents.
The Facility's policy does not really address the issue to provide adequate supervision and assistive devices to prevent accidents.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.