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Inspection visit

Inspection

Avir at River ValleyCMS #4559702 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 Page 8 of 8

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Citations

2 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0622GeneralS&S Epotential for harm

    F622 - Transfer and discharge-

    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.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

FAQ · About this visit

Common questions about this visit

What happened during the January 16, 2025 survey of Avir at River Valley?

This was a inspection survey of Avir at River Valley on January 16, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Avir at River Valley on January 16, 2025?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.