Avir at River Ridge

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 2 (Resident #1 and Resident #2) of 5 residents reviewed for infection control practices. The facility failed to ensure Resident #1 and Resident #2 on EBP had correct EBP orders. The facility failed to ensure, during wound care with Resident #2, LVN-A correctly donned PPE (to don PPE means to put on personal protective equipment) prior to wound care, performed proper hand hygiene during wound care, correctly cleansed the wound during wound care, and correctly disposed of contaminated trash and supplies during wound care. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for two (Resident#1 and Resident #2), of five residents reviewed for care management, that was consistent with professional standards of practice, comprehensive person-centered care plan, and goals and preferences. On 02/16/2026 the facility failed to notify Resident #1's physicians' team when a MRSA critical laboratory result. On 02/18/2026 the wound care nurse failed to notify the physician when she was made aware of a skin irregularity on Resident #2 right big toe. This failure could place residents at risk of not receiving prompt medical intervention management.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #2) of five residents reviewed for wound care orders. The facility failed to ensure wound care orders were obtained for Resident #2's abdominal area wound from 02/12/2026 to 02/15/2026. This failure could place residents at risk for wound care complications or at risk of not receiving necessary wound care.

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for two (Resident #1) and (Resident #2) of five residents reviewed for wound care completion documentation. On 02/16/2026, LVN A failed to document wound care completion on Resident #1's TAR.On 02/15/2026-02/17/2026 the facility failed to document wound care completion on Resident #2's TAR.This failure could place residents at risk from accurately receiving and accounting for wound care completion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatments and services consistent with professional standards of practice to promote healing, prevent infection, and prevent development of new ulcers for 1 of 5 residents (Resident #50) reviewed for pressure ulcers. The facility failed to ensure Resident #50's Foley catheter was not leaking, causing the brief over the pressure ulcer to be saturated with urine, failed to ensure the WCN followed proper hand hygiene and clean glove protocol, failed to ensure incontinent care prior was provided prior to wound care; and failed to use proper wound care cleansing techniques. These failures and deficient practices could place residents at risk for cross contamination, infection, and new or worsening pressure ulcers.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #36 and Resident #19) reviewed for pharmacy services in that: The facility failed to compare the instructions written on Resident #36's blister pack with the physician's order for lisinopril (blood pressure medication) before it was administered on 01/28/26. The facility failed to ensure the nurse cart for 100-hall was free from expired insulin pens. The facility failed to ensure expired insulin was not administered to Resident #19 on 01/28/26. These failures could place residents at risk for non-therapeutic responses to medications.

Inspectors wroteBased 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 for 1 of 1 kitchen refrigerator, 1 of 1 kitchen freezer and 1 of 1 dry storage room reviewed for sanitation and storage. 1. The facility failed to ensure items in the refrigerators were sealed.2. The facility failed to ensure items in the freezers were sealed, labeled, and dated.3. The facility failed to ensure items stored in the dry storge room were correctly sealed, dated, and labeled.4. The facility failed to ensure stove and oven were cleaned. 5. The facility failed to ensure utensils were free from scratches and food residue. 6. The facility failed to discard a pan with the non-stick coding scratched off. 7. The facility failed to keep the kitchen room walls and floor were clean.8. [...]

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 12 of 12 residents reviewed for infection control practices. The facility failed to ensure all residents on EBP in the facility had EBP signs posted on residents' doors or walls outside of the rooms. The facility also failed to ensure the WCN and CNA-H followed properly sanitized their hands and changed their gloves during wound and incontinent care on 01/28/2026 for Resident #50's The WCN and CNA-H also failed to sanitize hands and apply clean gloves prior to getting wipes out of the clean container of wipes. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen and the rest of the facility for rodents. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk for needs and accommodations being unmet. Record review of a face sheet dated 9/29/2025 indicated Resident #1 was a [AGE] year-old who was admitted on [DATE] with diagnoses of Nontraumatic Intracerebral Hemorrhage (a type of stroke where bleeding occurs within the brain tissue without any external injury), Flaccid Hemiplegia affecting the right dominant side(weakness or paralysis on one side of the body), Aphasia (a language disorder that affects a person's ability to communicate), and Dysphagia (difficulty swallowing food or liquid). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for supervision.1. The facility failed to ensure CNA A followed 2-person assist as stated on Resident #1's care plan when she transferred Resident #1 from her wheelchair to bed on 11/01/25 at around 7:00 PM.2. The facility failed to ensure CNA A followed Resident #1's care plan and used a 2 person assist when she provided incontinent care on 11/01/25 around 8:30 PM and on 11/02/25 around 4:00AM. Which resulted in acute proximal and mid left lower leg fractures. An Immediate Jeopardy (IJ) was identified on 11/08/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #3) reviewed for medical records accuracy, in that: The facility failed to transcribe Resident #'3's paper care plan to her electronic care plan that was accessible by staff. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care, treatment and medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for sanitation. The facility failed to label and date prepared refrigerated drinks and puree. The facility failed to ensure ingredients were not left open to air in the dry storage room freezer, and on prep tables. The facility failed to ensure the kitchen was free of gnats. The facility failed to ensure personal items were not on a prep table. The facility failed to ensure dirty dishes were not on the clean rack. The facility failed to ensure the ice machine, non-stick pans, and a large spatula was maintained and sanitary. The facility failed to ensure items in the kitchen were clean. The facility failed to store cases of food off the floor in the freezer. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 (Resident #39) of 8 residents reviewed for abuse and neglect, in that: LVN A did not implement facility abuse policy related to reporting allegations of abuse to Resident #39's RP when CNA C was alleged to have abused Resident #39 on 10/22/24. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 2 (Residents #48 and #25) residents of 5 residents reviewed for PASRR screenings. 1. The facility failed to ensure Resident #48 had an accurate PASRR Level 1 screening 2. The facility failed to ensure Resident #25 had an accurate PASRR Level 1 screening These failures placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 1 (Resident #140) of 8 residents whose care plans were reviewed for timing and revision. Resident #140's care plan was not revised after self-removal of her tracheostomy tube. Resident #140's care plan was not revised after her tracheostomy sutures were removed. Resident #140's care plan was not revised after pleasure feeding was discontinued and changed to a pureed diet. Resident #140's care plan was not revised after enteral feedings were discontinued. These failures could place residents at risk for inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of one out of three medication cart (200-hall Medication Cart) reviewed for storage, in that: The facility failed to ensure the 200-hall Medication Cart was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #61) of 4 residents reviewed for infection control practices, in that: The facility failed to ensure LVN E wore proper PPE during wound care for Resident #61 who required enhanced barrier precautions. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 (Resident #21) of 3 residents reviewed for change in condition. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm reflected that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room three days before the x-ray was completed on 11/28/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #21) of 3 residents reviewed for diagnostic services. 1. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm revealed that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room on 11/25/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #21) of 3 residents reviewed for care plans in that: 1. The facility failed to retain Resident #21's DNR (Do Not Resuscitate) code status on the comprehensive care plan when Resident #21 was transferred to the hospital. 2. The facility failed to ensure Resident #21's DNR code status was included in Resident #21's comprehensive care plan when it was signed by the physician on [DATE]. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 (Resident #21) of 3 residents reviewed for care plan timing. The facility failed to ensure that Resident #21's comprehensive care plan was developed within 7 days of a comprehensive assessment or within 21 days of Resident #21's admission date of 10/27/23 and comprehensive assessment date of 10/31/23. These failures could place residents at risk of not receiving individualized care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission for one (Resident #1) of two residents reviewed for baseline care plans, in that: The facility failed to develop a care plan within 48 hours of Resident #1's return from the emergency room that addressed Resident #1's wound care needs or address emergency management in the event of suture displacement. This failure could affect the resident's healthcare needs and risks the resident to suffer pain, loss of blood or infection.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility failed to ensure nursing staff documented, monitored, and assessed Resident #1's sutures for 5 days. This failure could affect residents by placing them at risk of delayed medical treatment, hospitalization, or a decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure residents received Nursing Services in accordance with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility failed ensure nursing staff documented, monitored, and assessed Resident #1's sutures for 5 days. The facility failed to ensure nursing staff assessed Resident #1 for pain before attempting wound care. This failure could affect residents by placing them at risk of delayed medical treatment, hospitalization, or a decline in condition.

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, the comprehensive person-centered care plan, and the resident's choices for two (Resident #54, Resident #59) of 18 residents whose care were reviewed, in that: 1. Wound Care Nurse did not follow doctor's orders (pat dry wound) for treatment of wound care for Resident #54. 2. The facility failed to assess and provide treatment for redness/rash on Resident #59's forehead and scalp. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, including expiration dates for, 1 of 4 medication carts and 1 of 1 medication room reviewed for expiration dates and proper storage. There were loose medications in medicine cups inside a medication cart The temperature logs in the medication room for the freezer, medication refrigerator, and specimen refrigerator (small fridge) were not completed

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition room, in that: There was an open package of cereal There was expired food in the refrigerator Food products were not discarded on or before the expiration date in the nutrition room The temperature logs in the nutrition room refrigerator were not completed The facility failed to ensure the nutrition room freezer had a thermometer and the freezer log for temperature was not completed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident #54 (R #54) of two residents observed for infection control practices during personal care, in that: 1.) Wound care nurse: -performed hand hygiene for approximately 5 seconds after glove change -performed hand hygiene for approximately 6 seconds after end of care and glove removal This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.