Avir at River Valley

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility (Facility #1) reviewed for nursing services. The facility did not have RN coverage for two days on 06/13/26 or 06/14/26. This failure could place the residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (300 Hall and 400 hall) out of 3 hallways reviewed for accidents and hazards. The facility failed to ensure that the mechanical lifts on 300 hall and 400 halls were locked and secured when not in use. This failure could place residents at risk of falls and/or injuries. Findings Included: Observation on 05/17/26 at 10:17 AM of 300 hall revealed an unlocked and unsecured mechanical lift parked on the hallway where residents were observed maneuvering their wheelchairs around the Hoyer lift. Observation on 05/17/26 at 10:24 AM of 400 hall revealed an unlocked and unsecured mechanical lift parked along the wall of the hallway near resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to the meet the needs of each resident for 3 Residents (Resident# 37, Resident#6, and Resident#39) of 6 Residents reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #6's Hydrocodone 5-325mg (controlled medication) by taping a narcotic medication and storing it in the 100-hall medication cart. The facility failed to ensure proper disposal of Resident #39's Acetaminophen 300-30mg (controlled medication) by taping a narcotic medication and storing it in the 100-hall medication cart. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #21) reviewed for comprehensive care plans. The facility failed to ensure Resident #21's comprehensive care plan identified bed rail use as an intervention for mobility assistance. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident# 19) of 6 reviewed for medication storage. 1. The facility failed to ensure Resident #19's Advair (a prescription inhaler used as a maintenance treatment to prevent breathing difficulties, wheezing, and chest tightness) was secured in the medication cart. These failures could place residents at risk for compromised unsafe administration, and increased harm to residents.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement smoking safety policies and procedures for 2 (Resident #20 and Resident #32) of 6 residents reviewed for smoking safety. The facility failed to complete an initial smoking assessment for Resident #20 and Resident #32 to determine the resident's need for supervision in accordance with facility smoking policies. This failure placed residents at risk for smoking related accidents, burns, and other safety hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable disease and infections for 1 of 2 residents (Resident #1) reviewed for infection control. CNA A failed to perform hand hygiene during gait belt transfer on 10/09/25 for Resident #1. This failure could place residents at risk of cross-contamination and the development of infections. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (CNA A) of six employees reviewed for abuse and neglect. The facility failed to conduct criminal background checks for CNA A. These failures could place residents at risk for abuse and receiving care from unemployable staff.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 1 of 3 holidays ([DATE]) and 32 out of 34 weekend day ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]) from [DATE] to February 2025. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for one (Resident #35) of five residents reviewed for pharmacy services. 1. LVN C failed to hold medication as ordered by physician and administered Lantus insulin 20 units on 02/10/25, 02/16/25, 02/19/24, 02/20/24 when FSBS was below 150. 2. LVN D failed to document he withheld Lantus medication on 02/03/25 and 02/18/25. These failures could place residents at risk of bleeding, result in an adverse reactions to medications, not being monitored for side effects to medications, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents observed (Resident#2 and Resident #25)) for infection control. 1. The facility failed to ensure CNA A completed hand hygiene while performing incontinent care for (Resident #2). 2. The facility failed to ensure CNA B did not use the same gloves throughout the procedure of incontinence care for Resident #25 on 02/25/25. This failure could place the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #25) of two residents reviewed for incontinence care. The facility failed to ensure CNA B cleaned the labia from the inside outward to the thighs during perineal care for Resident #25 on 02/25/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure stove burner drip pan was emptied and free of food particles. This failure could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on interview and record review the facility failed to ensure all necessary documentation of discharge was in the medical record for four of six residents (Residents #5, #6, #7 and #8) reviewed for discharge The facility failed to ensure discharge summary completed for planned discharge for Residents #5, #6, #7 and #8. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for four of eight residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for pharmacy services. The facility staff failed to accurately document administration of prn pain medications to Resident's #1, Resident #2, Resident #3, and Resident #4. This failure could affect residents receiving medications and place them at risk of missed doses of medications, inaccurate records, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 10 of 16 weekends (09/02/23, 09/03/23, 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/14/23, 10/15/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/17/23, 11/18/23, 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23 and 12/17/23) from September to December 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Resident #34 and Resident #6 ) of 11 residents reviewed for comprehensive care plans. 1) The facility failed to implement Resident #34's comprehensive person-centered care plan failed to address their activity needs. 2) The facility failed to implement Resident #6's comprehensive person-centered care plan for plastic utensils for two meals. This failure could affect all residents by placing them at risk of not having their choices and preferences of activities care planned and/or provided.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain oven equipment in safe operating condition in facility's only kitchen reviewed for physical environment. The facility failed to ensure the stove and oven were in good working condition with no missing control knobs or loose handles. This failure places residents at risk of injury due to fire or foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.for 1 of 1 medication carts reviewed for pharmacy services. The facility failed to ensure Resident #31 did not have expired medication of Zofran in the nurse medication cart. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, 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 for 1 of 1 medication carts reviewed for pharmacy services. 1. The facility failed to ensure 2 unidentified pills were stored properly in nurse medication cart. 2. The facility failed to ensure nurse medication cart was free of cracks and in good working condition to ensure proper storage for resident medications. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of two residents (Resident #1) observed for infection control. The facility failed to ensure TCNA A performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk for infection.