Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Golfcrest during CMS and state inspections, most recent first.
A resident who was care planned for two-person assistance during ADLs and transfers slid from an elevated bed while a CNA was changing linens with only one staff member present. The resident sustained a forehead hematoma and skin tears, was sent to the hospital after a witnessed fall, and later expired. Interviews and record review confirmed the resident required x2 assistance, but only one CNA provided care at the time of the incident.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility failed to ensure that MDS assessments accurately reflected the dental and mental health status of four residents. Inaccuracies included documenting the presence of natural teeth when residents were edentulous or had significant dental issues, and omitting mental illness diagnoses despite clear evidence in clinical records and PASRR evaluations. These discrepancies were identified through interviews, observations, and review of dental and medical records.
A medication error rate of 10% was identified when staff failed to administer chewable aspirin as directed and gave an incorrect dose of Vitamin D3 to three residents, despite clear orders and ongoing staff education. Errors included not instructing residents to chew aspirin and administering a higher-than-ordered dose of cholecalciferol.
A resident with a history of hemiplegia and hemiparesis was later diagnosed with bipolar disorder and anxiety disorder and prescribed antipsychotic medication, but staff did not refer for a required PASRR Level II evaluation. The social worker and MDS Coordinator lacked formal PASRR training and were unaware of the new diagnoses, resulting in no referral or updated documentation. Facility leadership did not have clear oversight or training processes to ensure PASRR compliance.
A resident with multiple diagnoses was admitted to an LTC facility without a timely PASARR assessment, risking unmet service needs. The assessment, crucial for identifying necessary specialized services, was delayed due to the social worker's illness. Interviews revealed a lack of coordination in the PASARR process, highlighting the importance of timely assessments as per federal requirements.
A resident with major depressive disorder and intellectual disability was admitted without a timely PASRR assessment, leading to a delay in identifying necessary services. The social worker's illness contributed to the delay, and facility staff acknowledged the failure to comply with PASRR procedures.
A resident with a history of mental health disorders was subjected to mental abuse by a CNA during a nephrology appointment. The CNA allegedly used a racial slur, causing the resident to become withdrawn. The incident was reported by a Patient Affairs Specialist, but the facility failed to respond appropriately, violating the resident's right to be free from abuse.
Failure to Provide Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent an accident for a resident who required two-person assistance for ADLs and transfers. The resident’s record showed diagnoses including heart failure, thrombocytopenia, intracranial hemorrhage, hemiplegia, hemiparesis, and deep vein thrombosis. The annual MDS coded the resident as severely impaired and dependent for two-person assistance with showers, toileting, hygiene, and bed transfers. The care plan identified the resident as at risk for falls related to poor safety awareness and poor balance and directed that a mechanical lift with staff x2 be used for transfers and that total assistance x2 staff be provided for ADLs. During linen change and ADL care, only one CNA was present even though the resident required two-person assistance. The CNA reported that he requested help from two other CNAs, but assistance was not immediately available, so he began changing the bed linen while waiting. He stated the bed was elevated and the resident slid from the bed to the floor, landing face down. A progress note documented that staff found the resident on the floor face down, with a raised area to the forehead and open skin sites to the right arm. The resident was nonverbal but responded to verbal stimulus by nodding. Nursing staff performed an assessment, applied ice to the forehead, initiated neuro checks, and called 911. The EMS report documented transport to a local hospital for a witnessed fall with a forehead hematoma. The facility’s incident investigation described the event as a witnessed fall during linen change when the resident slid out of bed. Interviews with the DON, Administrator, CNA, and LVN confirmed that the resident was care planned for two-person assistance, but only one staff member provided care at the time of the incident. The report also states that the resident expired in the hospital the following day.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Inaccurate MDS Assessments for Dental and Mental Health Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of four residents. For one resident, the annual MDS assessment indicated the presence of all natural teeth without problems, despite dental records and direct observation confirming the absence of natural teeth and the presence of inflamed, swollen, and bleeding gums. This resident was observed on a pureed diet and verbally confirmed having no teeth during an interview. Another resident's annual MDS assessment also inaccurately documented the presence of all natural teeth without problems, even though the resident reported ongoing dental pain, loss of teeth, and the use of oral gel for pain relief. The resident had not communicated the specific nature of his dental pain to staff, and the nursing and MDS staff were unaware of his dental issues at the time of assessment. The resident's care plan was later updated to reflect dental concerns, but the original MDS did not capture these issues. A third resident's MDS assessment failed to document a mental illness condition, leaving the relevant section blank, despite the resident having diagnoses of bipolar disorder and schizophrenia, and a PASRR evaluation confirming serious mental illness. For a fourth resident, the MDS assessment indicated edentulism (no natural teeth), but the resident reported having several teeth remaining, and dental records supported the presence of non-restorable teeth recommended for extraction. These inaccuracies in the MDS assessments were identified through record review, observation, and interviews, and were not consistent with the residents' actual conditions as documented in other clinical records and direct statements.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as evidenced by a 10% error rate observed during medication administration. Specifically, three out of thirty medication administration opportunities resulted in errors involving three residents and two staff members. For two residents with severe cognitive impairment, staff administered chewable aspirin tablets without instructing or ensuring the residents chewed them, resulting in the tablets being swallowed whole. In another instance, a resident was given a higher dose of cholecalciferol (Vitamin D3) than ordered, receiving 125 mcg (5000 IU) instead of the prescribed 50 mcg (2000 IU). Record reviews confirmed that the medication orders were clear regarding the form and dosage to be administered, and medication administration records matched these orders. Observations showed that staff did not follow the specific administration instructions, and interviews with facility leadership and staff confirmed ongoing education and competency checks related to medication administration. However, these measures did not prevent the observed errors, which were directly related to staff actions during medication pass.
Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR (Preadmission Screening and Resident Review) evaluation after new mental health diagnoses were identified. The resident, a female with a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with no documented mental illness at the time of her initial PASRR Level I screening. However, subsequent medical records showed new diagnoses of bipolar disorder and anxiety disorder, and the resident was prescribed antipsychotic medication for bipolar disorder with psychotic features. Despite these new diagnoses, the facility did not initiate a referral for a Level II PASRR evaluation as required. The social worker responsible for the initial PASRR Level I screening stated that she was unaware of the need for further evaluation and had not received formal PASRR training at the time. The MDS Coordinator also indicated a lack of familiarity with the PASRR process, including when to use specific forms, and had not received formal PASRR training during her tenure. Both staff members were unaware of the updated mental health diagnoses and did not complete the necessary documentation or referrals. Interviews with facility leadership revealed that there was no clear oversight or training structure in place to ensure staff responsible for PASRR were adequately trained or aware of their responsibilities. The Director of Nursing and Administrator were not aware of the changes in the resident's diagnoses or the requirements for PASRR referrals following new mental health findings. Facility policy required PASRR Level I completion prior to admission and Level II evaluation for residents with mental illness, but this was not followed in the case of the resident with new psychiatric diagnoses.
Failure to Timely Complete PASARR Assessment
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident, resulting in a deficiency. The resident, a female with multiple diagnoses including major depressive disorder, moderate intellectual disabilities, and Parkinson's disease, was admitted to the facility without a PASARR assessment completed within the required 20 days. This oversight could potentially place newly admitted residents at risk of not receiving necessary services to meet their needs. The resident's records indicated a PASARR Level 1 Screening was completed, identifying intellectual developmental disability and recommending specialized services such as physical and occupational therapy. However, the PASARR evaluation was not completed in a timely manner due to the social worker's illness, leaving no one else at the facility to perform the assessment. The social worker acknowledged the importance of completing the PASARR assessment promptly to ensure residents receive the services they need. Interviews with facility staff, including the social worker and MDS coordinators, revealed a lack of coordination and communication regarding the PASARR process. The MDS Coordinator, who had been at the facility for only a month, stated that the PASARR should be completed within 20 days to identify residents' needs accurately. The facility's handbook outlines the federal requirements for PASARR, emphasizing the necessity of timely assessments to ensure appropriate services for residents with mental illness, intellectual disabilities, or developmental disabilities.
Failure to Complete Timely PASRR Assessment
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the status of a resident with a diagnosis of major depressive disorder and intellectual disability. The resident did not receive a PASRR Level II assessment or evaluation within the required timeframe. This oversight was identified for one of the twelve residents reviewed for PASRR assessments. The resident, a female with multiple diagnoses including major depressive disorder, intellectual disability, and Parkinson's disease, was admitted to the facility without a completed PASRR assessment within 20 days of admission. The resident's baseline plan of care was incomplete, lacking focus, goals, and interventions. The PASRR Level I screening was conducted by the social worker, who confirmed the presence of intellectual disability, but the assessment was not completed in a timely manner due to the social worker's illness and absence. Interviews with facility staff, including the social worker and MDS coordinators, revealed a lack of compliance with PASRR assessment procedures. The social worker acknowledged the delay in completing the PASRR assessment and its importance in ensuring residents receive necessary services. The MDS coordinators confirmed the facility's failure to complete the PASRR assessment within the required timeframe, which could result in residents not receiving the services they are entitled to.
Resident Subjected to Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from mental abuse during a nephrology appointment at a hospital. A Certified Nursing Assistant (CNA) allegedly yelled at the resident and used a racial slur, which is a violation of the resident's right to be free from abuse. The incident was reported by a Patient Affairs Specialist who witnessed the CNA's behavior and noted that the resident became quiet and withdrawn after the incident. The resident involved in the incident is a male with a history of major depressive disorder, bipolar disorder, obesity, type 2 diabetes mellitus, and anxiety disorder. His cognitive abilities are mildly impaired, and he requires assistance with various daily activities. During an interview, the resident confirmed the use of the racial slur by the CNA, although he did not report the incident to anyone at the time. The facility's policy on abuse prohibition states that residents have the right to be free from verbal, sexual, physical, and mental abuse. The policy also requires that all alleged violations be reported immediately to the administrator or designee. However, the report indicates that the facility did not respond appropriately to the incident, as the Patient Affairs Specialist's attempt to report the incident was met with rudeness, and no follow-up was conducted by the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Courtyard | 0.5 mi | ★★★★★ | 8 | 0 |
| Afton Oaks Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 12 | 7 |
| Harmony Care At Golfcrest | 2.5 mi | ★★★★★ | 7 | 0 |
| Paradigm At Faith Memorial | 5 mi | ★★★★★ | 18 | 0 |
| Richard A. Anderson (state Of Texas Veterans Land | 5.7 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.