F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
1. Record review of Resident #5's face sheet, undated, revealed she was a [AGE] year-old female admitted
to the facility on [DATE], with a planned discharge to another facility on 08/12/2024. Resident #5 had the
diagnoses of dementia (loss of cognition), dysphagia (swallowing difficulties), and a cognitive
communication deficit.
Record review of Resident #5's care plan revealed a goal of .Resident has no planned discharge plan at
this time and will reside at the facility. with a long term goal target date of 10/17/2024 and edited on
07/17/2024 by RN G .
Record review of Resident #5's Discharge MDS assessment, dated 08/12/2024, revealed resident had a
planned discharge to a skilled nursing facility on 08/12/2024, and had a BIMS score of 3 (severely impaired
cognition).
Record review of Resident #5's progress notes revealed a progress note dated 08/12/2024, written by LVN
C Resident #5 was discharged from facility with family member with all medications accounted for and
instructions and was .alert and oriented x's1 .
Review of Resident #5's clinical record reflected no discharge assessment or summary for Resident #5.
2. Record review of Resident #6's face sheet, undated, reflected she was a [AGE] year-old female admitted
to the facility on [DATE] with a planned discharged on 05/20/2024 to another facility. Resident #6 had the
diagnoses of hydrocephalus (fluid in the brain), epilepsy (a seizure disorder), and intellectual disabilities.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
455970
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #6's Discharge MDS assessment, dated 05/20/2024, reflected resident had a
planned discharge to skilled nursing facility on 05/20/2024, with a blank BIMS score.
Record review of Resident #6's care plan start date of 6/7/23 edited 4/17/24 revealed a goal of .Resident
has no planned discharge plan at this time and will reside at the facility .
Residents Affected - Some
Record review of Resident #6's progress notes revealed a nursing note, dated 05/20/2024, written by LVN
C, resident was discharged from facility with her family member via a private vehicle and educated on all
medications.
Review of Resident #6's clinical record reflected no discharge assessment or summary for Resident #6.
Interview on 01/15/2025 at 2:45 PM with the Administrator revealed Resident #6 had dementia and had a
decline. He stated she had a planned discharge and transferred to a facility with a secure unit due to her
dementia. He stated Resident #5 had a planned discharge to another facility.
3. Record Review of Resident #7's face sheet, date printed 01/16/25, reflected she was a [AGE] year-old
female admitted to the facility on [DATE] and discharged to the community/home on [DATE]. Resident #7
had diagnoses of heart failure and diabetes.
Record review of Resident #7's comprehensive care plan dated 02/25/24 reflected [Resident #7]'s
discharge plans are to [discharge] home to own apartment independently.
Record review of Resident #7's Discharge MDS assessment, dated 04/29/2024, reflected Resident #7 had
a planned discharge with return not anticipated to home/community on 04/29/24.
Record review of Resident #7's April 2024 progress notes reflected a progress note dated 04/29/24 by LVN
A, Resident #7 discharged with all meds and belongings.
Review of Resident #7's clinical record reflected no discharge assessment or summary for Resident #7.
Interview on 01/15/2025 at 4:22 PM with LVN A revealed nursing was not responsible to complete and
initiate the discharge summary. She stated she thought the social worker was responsible to ensure the
discharge summary was completed. She stated she documents resident receiving their medications at
discharge in a nurse progress note. LVN A stated Resident #7 was a planned discharged to a group home
and she was the discharging charge nurse for Resident #7. She stated she provided Resident #7's
medications at time of discharge.
4. Record review of Resident #8's face sheet, undated reflected she was an [AGE] year-old female admitted
to the facility on [DATE] with diagnoses of orthopedic aftercare, osteoarthritis ( at type of arthritis that
occurs when flexible tissue at the ends of the bones wears down), epilepsy ( abnormal electrical brain
activity that causes seizures), atrial fibrillation (irregular heart rhythm) and chronic kidney disease (long
term condition that occurs when the kidneys are damaged and can not filter blood properly Resident #8
was discharged on 06/17/2024 to home.
Record review of Resident #8's Discharge MDS assessment dated [DATE] reflected Resident #8 had a
planned discharged with return not anticipated to home/community on 06/17/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
Record review of Resident #8's June 2024 progress notes reflected the following:
Level of Harm - Minimal harm
or potential for actual harm
- dated 06/17/24 by LVN H Transport here to pick up resident. Resident being discharged home with
hospice .Call placed to hospice provider to confirm discharge.
Residents Affected - Some
- dated 06/17/24 by LVN H Resident discharged home. Resident transported via stretcher with two
attendants. All meds sent with resident. Physician notified.
- dated 06/17/24 by previous SW The MSW spoke with [family member] this A.M. to inform him that the
resident's cell phone and clothes were left in the room. [Family member] confirmed that he would pick up
the items this evening.
Review of Resident #8's clinical record reflected no discharge assessment or summary for Resident #8.
Interview on 01/15/2025 at 3:15 PM with LVN E revealed he usually worked the 6 pm to 6 am shift but was
working the day shift today to assist with staffing needs. He stated the facility had not inserviced on
discharge planning. He did not know about discharge documentation required for planned resident
discharges. He stated residents had planned discharges usually on the day shift.
Interview on 01/15/2025 at 9:06 PM with LVN F he stated he was not sure who was responsible for initiating
the discharge summary and thought management or the charge nurse. He stated he worked nights and
residents do not usually discharge on his shift. He stated that when a resident discharged there was
planning that occurred to ensure it was a safe discharge with management was involved and they probably
started the discharge summary. He stated the nurses were responsible for charting an ending progress
note in the resident's chart. He stated the discharge summary was important because it ensured the
resident received proper services and had a safe discharge with items like medications and home health.
Interview on 01/16/2025 at 3:10 PM with the Administrator and DON revealed the social worker was
responsible to ensure the discharge summary was initiated but the charge nurse could initiate it if social
worker had not initiated it. The Administrator stated the previous social worker had left in October 2024 and
hired a new social worker who had been at facility for the last month. He stated during the time the facility
was without a social worker the charge nurse was responsible for discharge planning but had not
specifically had an inservice with charge nurses to ensure nursing was aware discharge summaries
needed to be completed by charge nurse. The DON stated charge nurses would ensure residents were
provided at time of discharge the continuity care document which included current medication list and
diagnoses along with their medications.
Interview on 01/16/2025 at 4:40 PM with DON revealed she could not find the discharge summaries for
Residents #5, #6, #7, and #8. She stated it was important for nurses to complete discharge planning
documentation in the discharge summary to ensure discharge planning and needs were met. She stated at
previous facility she was used to the social worker ensuring the discharge summary was completed. She
stated she started at the end of April 2024 as the DON. She stated going forward she would follow-up with
charge nurse and SW to ensure discharge summary completed for planned resident discharges.
Record review of facility's policy Discharge Summary and Plan dated December 2016 reflected When a
resident's discharge is anticipated, a discharge summary .will be developed to assist the resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
to adjust to his/her new living environment.
Level of Harm - Minimal harm
or potential for actual harm
1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility
(i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be
developed which will assist the resident to adjust to his or her new living environment. 2. The discharge
summary will include a recapitulation of the resident's stay at this facility and a final summary of the
resident's status at the time of the discharge in accordance with established regulations governing release
of resident information and as permitted by the resident. The discharge summary shall include a description
of the resident's:
Residents Affected - Some
a. current diagnosis; b. medical history (including any history of mental disorders and intellectual
disabilities);
c. course of illness, treatment and/or therapy since entering the facility; d. current laboratory, radiology,
consultation, and diagnostic test results; e. physical and mental functional status; f. ability to perform
activities of daily living including:
(1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech,
language, and other communication systems; (2) the need for staff assistance and assistive devices or
equipment to maintain or improve functional abilities; and (3) the ability to form relationships, make
decisions including health care decisions, and participate (to the extent physically able) in the day-to-day
activities of the facility. g. sensory and physical impairments (neurological, or muscular deficits; for example,
a decrease in vision and hearing, paralysis, and bladder incontinence); h. nutritional status and
requirements: (1) weight and height; (2) nutritional intake; and (3) eating habits, preferences and dietary
restrictions. i. special treatments or procedures (treatments and procedures that are not part of basic
services provided); j. mental and psychosocial status (ability to deal with life, interpersonal relationships and
goals, make health care decisions, and indicators of resident behavior and mood);
k. discharge potential (the expectation of discharging the resident from the facility within the next three
months); l. dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may
affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of
dentures or other dental appliances); m. activities potential (the ability and desire to take part in activity
pursuits which maintain or improve physical, mental, and psychosocial well-being);
n. rehabilitation potential (the ability to improve independence in functional status through restorative care
programs);
o. cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety
hazards); and
p. medication therapy (all prescription and over-the-counter medications taken by the resident including
dosage, frequency of administration, and recognition of significant side effects that would be most likely to
occur in the resident). 3. As part of the discharge summary, the nurse will reconcile all pre-discharge
medication with the resident's post-discharge medications. The medication reconciliation will be
documented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
1. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old
female with an admission date of 11/17/17. Resident #1 had a BIMS score of 10 which indicated she was
moderately cognitively intact. She had received PRN pain medication in the last 5 days. Diagnoses included
diabetes and frequent falls.
Record review of Resident #1's Physician order report, dated 01/15/25 reflected,
hydrocodone-acetaminophen tablet 10-325 mg (narcotic for pain control) 1 tablet every four hours as
needed .
Record review of Resident #1's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet
10-325 mg reflected from 01/04/25 through 01/16/25 LVN C had signed out on 01/04/25-4 tablets,
01/05/25-4 tablets, 01/08/25-4 tablets, 01/09/25- 5 tablets (1 was wasted), 01/13/25-4 tablets, 01/14/25-4
tablets, LVN A-signed out 01/06/25-4 tablets, 01/07/25-3 tablets, 01/10/25-3 tablets, 01/11/25-3 tablets,
01/12/25-3 tablets, 01/15/25-3 tablets, 01/16/25-2 tablets , and LVN D signed out 01/07/25-1 tablet,
01/10/25-1 tablet, 01/11/25-1 tablet and 01/15/25-1 tablet.
Record review of Resident #1's Medication Administration record for January 2025 for
hydrocodone-acetaminophen tablet 10-325 mg reflected no administration of the medication from 01/01/25
through 01/15/25.
2. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old
female with an admission date of 12/15/23. Resident #2 had a BIMS score of 15 which indicated she was
cognitively intact. She had received both scheduled and PRN pain medications in the past 5 days.
Diagnoses included pain and neuropathy (condition that affects the nerves in the body).
Record review of Resident #2's Physician order report, dated 01/15/25 reflected,
hydrocodone-acetaminophen tablet 7.5-325 mg (narcotic for pain control) 1 tablet every four hours as
needed .
Record review of Resident #2's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet
7.5-325 mg reflected from 01/10/25 through 01/15/25 LVN A had signed out 01/10/25-2 tablets, 01/11/25-4
tablets, 01/12/25-4 tablets, 01/15/25-5 tablets, 01/16/25-1 tablet, LVN C-signed out 01/13/25-2 tablets,
01/14/25- 2 tablets, and LVN D signed out 01/12/25-1 tablets, 01/16/25 1 tablet.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #2's Medication Administration record for January 2025 for
hydrocodone-acetaminophen tablet 7.5-325 mg reflected no administration of the medication from 01/01/25
through 01/14/25. LVN A signed out administration of 1 tablet on 01/15/25 at 1:36 p.m.
3. Record review of Resident #3's quarterly MDS assessment dated [DATE]/24 reflected a [AGE] year-old
female with an admission date of 04/27/23. Resident #3 had a BIMS score of 15 which indicated she was
cognitively intact. She had not received PRN pain medication in the last 5 days. Diagnoses included
diabetes and muscle weakness.
Record review of Resident #3's Physician order report, dated 01/15/25 reflected, oxycodone 5mg (narcotic
for pain control) 1 tablet every four hours as needed .
Record review of Resident #3's-controlled drug record on 01/15/24 for oxycodone 5mg reflected from
01/01/25 through 01/15/25 LVN A had signed out 01/01/25-4 tablets, 01/02/25-4 tablets, 01/06/25-4 tablets,
01/07/25-4 tablets, 01/10/25-4 tablets, 01/11/25-4 tablets, 01/12/25-4 tablets, 01/15/25-4 tablets, LVN C
signed out 01/03/25-4 tablets, 01/04/25-4 tablets, 01/05/25-4 tablets, 01/08/25-4 tablets, 01/09/25-5 tablets
(1 tablet was wasted), 01/13/25-4 tablets, 01/14/25-4 tablets, LVN E signed out 01/03/25-1 tablets,
01/04/25-1 tablet, 01/08/25-1 tablets, 01/09/25-1 tablet, 01/13/25-1 tablets, 01/14/25-1 tablets, and LVN D
signed out 01/01/25-1 tablet, 01/02/25-1 tablet, 01/06/25-1 tablet, 01/07/25-1 tablet, 01/10/25-1 tablet,
01/11/25-1 tablet, 01/12/25-1 tablet.
Record review of Resident #3's Medication Administration record for January 2025 for oxycodone 5mg
reflected no administration of the medication from 01/01/25 through 01/15/25.
4. Record review of Resident #4's 5-day MDS assessment dated [DATE] reflected a [AGE] year-old female
with an admission date of 08/15/24. Resident #4 had a BIMS score of 15 which indicated she was
cognitively intact. She had received PRN pain medications in the past 5 days. Diagnoses included cancer
and chronic lung disease.
Record review of Resident #4's Physician order report, dated 01/15/25 reflected,
hydrocodone-acetaminophen tablet 7.5-325 mg (narcotic for pain control) 1 tablet every four hours as
needed .
Record review of Resident #4's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet
7.5-325 mg reflected from 01/01/25 through 01/15/25 LVN A had signed out 01/01/25-4 tablets, 01/02/25-4
tablets, 01/06/25-4 tablets, 01/07/25-4 tablets, 01/10/25-4 tablets, 01/11/25-4 tablets, 01/12/25-4 tablets,
01/15/25-3 tablets, LVN C- signed out 01/03/25-4 tablets, 01/04/25-4 tablets, 01/05/25-4 tablets, 01/08/25-4
tablets, 01/09/25-4 tablets, 01/13/25-4 tablets, 01/14/25-4 tablets, LVN D signed out 01/02/25-1 tablets,
01/03/25-1 tablets, 01/06/25-1 tablet, 01/07/25-1 tablet, 01/08/25-1 tablet, 01/10/25-1 tablet and LVN E
signed out 01/03/25-1 tablet, 01/10/25-1 tablet.
Record review of Resident #4's Medication Administration record for January 2025 for
hydrocodone-acetaminophen tablet 7.25-325 mg reflected no administration of the medication from
01/01/25 through 01/14/25. LVN A signed out administration of 1 tablet on 01/15/25 at 1:36 p.m.
During an observation, interview, and record review of the med cart for halls 200 and 300 on 01/15/25
beginning at 09:55 a.m, LVN A was asked for the narcotic drug count book. LVN A retrieved the book and
stated she needed to sign out for the medications she had administered this morning. LVN A was observed
going through the book and signed for numerous residents including Resident #1, Resident #2, Resident
#3, and Resident #4.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
In an interview with LVN A on 01/15/24 at 10:05 a.m. she stated they were supposed to sign the medication
out on the drug record with the time they pulled the medication. She stated the risk of not signing it out at
the time you could get busy and forgot to sign out and then the count would be off, or you give a medication
to soon to someone if some other nurse was covering your hall. She stated they were also supposed to
sign the MAR when the drug was administered. She stated she had not been signing off on the MAR
because she usually does not take her medication cart with her when she was administering PRN
medications. She stated by the time she got back to her computer the time would be off which would delay
the resident when the resident could get their next dose of medications. She stated she had been relying on
the times signed off in the narcotic drug record instead of the MAR.
In an interview with LVN B on 01/15/24 at 10:10 a.m. she stated they were supposed to sign out any
controlled drug on the narcotic drug sheet and on the MAR at the time of administration. She stated when
they signed out on the MAR for PRN drug administration it would prompt them to go back and evaluate for
effectiveness of the medication.
In an interview with Resident #3 on 01/15/24 at 10:40 a.m. she stated she was absolutely getting her pain
medications. She stated she had terrible joint point and could not go without her pain medications.
In an interview with Resident #1 on 01/15/24 at 10:45 a.m. she stated she had not had any issues with
getting her pain medications as needed. She stated she had lung cancer in the past and was afraid it had
returned. She stated she currently had a wound on her back, and they were taking good care of it.
In an interview with Resident # 4 on 01/15/24 at 03:05 p.m. she stated she was getting her medications like
clockwork. She stated you could set the clock on when she gets its. She stated she had a bad wound on
her bottom they had been treating. She stated it was slowly getting better.
In an interview with Resident #2 on 01/15/24 at 3:25 p.m. she stated she was getting her pain medications
as needed and stated her pain was kept in control.
In an interview with LVN C on 01/15/24 at 04:30 p.m. she stated she knew they were supposed to sign out
PRN medications on the MAR when they gave it. She stated honestly most of the residents on hall 200 and
300 their pain meds should be routine the way they were taking them. She stated signing out the
medication on the drug record and not MAR did not reflect an accurate picture of what medications the
resident had received.
Interview with the DON on 01/15/25 at 04:45 p.m. revealed she expected the charge nurses on the floor to
document on the MAR as well as the controlled count sheet when they administered controlled
medications. She stated failing to sign out at the time they pulled the medication from the cart and the time
they administered the medication could result in an inaccurate drug reconciliation and an inaccurate
medication administration. She stated this could lead to a resident getting a medication to soon and could
lead to drug diversion.
Interview with the Administrator on 01/15/25 at 04:50 p.m. revealed the management team recognized the
documentation problem after the surveyor brought it to their attention on the controlled count sheet as well
as on the MAR and all the nurses would be re-trained on the policy on documentation of the controlled
medication. He stated they would also be monitoring for compliance.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455970
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at River Valley
1907 Refinery Rd
Gainesville, TX 76240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Record review of facility policy on Controlled Substances, dated June 2022, reflected, .Accurate
accountability of the inventory of all controlled drugs is maintained at all times. When a controlled
substance is administered, the licensed nurse administering the medication immediately enters the
following information on the accountability record and the medication administration record (MAR):
Residents Affected - Some
1) Date and time of Administration (MAR, Accountability Record).
2) Amount administered (Accountability Record).
3) Remaining quantity (Accountability record).
4) Initials of the nurse administering the dose, completed after the medication is actually administered
(MAR, Accountability record).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455970
If continuation sheet
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