Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At River Valley during CMS and state inspections, most recent first.
A CNA failed to perform hand hygiene before assisting with a two-person gait belt transfer for a resident requiring substantial assistance with ADLs. The CNA had retrieved a wheelchair from another room and did not wash or sanitize hands before the transfer, contrary to facility policy and expectations confirmed by the DON.
A resident with diabetes received Lantus insulin on multiple occasions when blood sugar levels were below the physician-ordered threshold, as nursing staff either failed to recognize or document the special instructions to hold the medication. The MAR did not consistently reflect when the medication was withheld, and staff interviews revealed gaps in awareness and documentation of the order.
A CNA was hired without a required criminal background check, in violation of facility policy and federal regulations. Both the Administrator and HR Manager confirmed awareness of the requirement, but the check was not completed prior to employment, resulting in noncompliance with abuse prevention procedures.
The facility did not ensure RN coverage for at least 8 consecutive hours each day, as required, due to only having the DON as an RN and not utilizing agency staff for weekends or holidays. LVNs provided weekend coverage until a weekend RN supervisor was recently hired, resulting in multiple days without the mandated RN presence.
Two residents received incontinent care in which CNAs failed to change gloves and perform hand hygiene at appropriate times, including after cleaning soiled areas and before handling clean items. Both CNAs acknowledged the lapses, and the DON confirmed that these actions did not meet facility policy or expectations for infection prevention.
A CNA failed to follow proper perineal care procedures for a female resident with incontinence, including not cleaning the labia first and not moving from the inside outward to the thighs, as required by facility policy. The CNA also touched clean items and the environment with contaminated gloves, deviating from infection control protocols. The deficiency was observed and confirmed through interviews and record review.
Surveyors found that the kitchen's stove burner drip tray was not emptied or cleaned as required, with food particles and sticky substances present. The Dietary Manager confirmed the tray should have been cleaned after each meal, but this was not done, contrary to facility policy for food safety.
The facility failed to document discharge summaries for four residents, leading to potential risks in post-discharge care. Residents with various medical conditions, including dementia and epilepsy, were discharged without necessary documentation. Staff interviews revealed confusion over responsibility for discharge summaries, with some believing it was the social worker's duty and others the charge nurse's. The facility's policy required comprehensive discharge documentation, but lack of clarity and training contributed to the deficiency.
The facility failed to accurately document the administration of PRN pain medications for several residents, leading to discrepancies between controlled drug records and MARs. Interviews with LVNs revealed that medications were often signed out after administration, resulting in potential inaccuracies in drug reconciliation. The facility's policy requires immediate documentation to ensure accurate accountability of controlled drugs.
Failure to Perform Hand Hygiene Prior to Resident Transfer
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the area of hand hygiene during resident care. On the observed date, CNA A assisted with a two-person gait belt transfer for a male resident with dementia, hypertension, generalized muscle weakness, and cognitive communication deficit, who required substantial to maximal assistance with activities of daily living. CNA A retrieved the resident's wheelchair from another room and did not perform hand hygiene before assisting with the transfer, despite having sanitized hands prior to entering the room initially. This lapse was directly observed by surveyors during the transfer process. During interviews, CNA A acknowledged the failure to perform hand hygiene before the transfer and recognized the expectation to do so. The Director of Nursing (DON) confirmed that staff are expected to wash or sanitize hands prior to resident transfers, as outlined in the facility's hand hygiene policy. The policy, implemented in June 2025, requires all staff to perform proper hand hygiene before performing resident care procedures to prevent the spread of infection.
Failure to Follow Insulin Administration Orders and Documentation Requirements
Penalty
Summary
Licensed vocational nurses (LVNs) failed to follow physician orders regarding the administration of Lantus insulin for a resident with diabetes, heart failure, and respiratory failure. The physician order specified that Lantus should be held if the resident's fingerstick blood sugar (FSBS) was below 150. Despite this, LVN C administered 20 units of Lantus on multiple occasions when the FSBS was below the threshold, stating she was unaware of the special instructions and did not see them on the medication administration record (MAR). LVN D, while aware of the special instructions, failed to document when the medication was withheld as required. Record review showed that on several dates, Lantus was given to the resident when FSBS readings were below 150, contrary to the physician's order. Interviews confirmed that LVN C did not recognize the need to hold the medication, and LVN D did not consistently document when the medication was withheld. The facility's policy required medications to be administered as prescribed and for withheld doses to be properly documented, but these procedures were not followed in this case.
Failure to Conduct Required Criminal Background Check for CNA
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for one certified nursing assistant (CNA A) out of six employees reviewed. Specifically, the facility did not conduct a criminal background check for CNA A prior to her hire date, as required by the facility's own policies. Review of CNA A's personnel file confirmed the absence of a criminal background check, despite the facility's policy stating that such checks must be completed for all potential employees, volunteers, contractors, and students affiliated with academic institutions. Interviews with the Administrator and HR Manager confirmed that both were aware of the requirement to conduct criminal background checks upon hire. The HR Manager, who was hired after CNA A, stated he had received training on this requirement from corporate. The Administrator also acknowledged the importance of ensuring that employees are not barred from employment due to past allegations of abuse or neglect. Despite these acknowledgments, the required background check for CNA A was not completed, resulting in noncompliance with facility policy and federal regulations.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, there was no RN coverage for 8 consecutive hours daily on one holiday and on 32 out of 34 weekend days during the review period. The only RN on staff was the Director of Nursing (DON), who provided coverage during the week but was unable to cover weekends. The facility did not utilize agency staff to fill these gaps due to a corporate decision, and weekend nursing coverage was provided by LVNs instead of RNs. The facility had an open job posting for a weekend RN supervisor, but the position remained unfilled until recently. Interviews with the Administrator and DON confirmed that the lack of RN coverage on weekends and certain holidays was due to staffing shortages and corporate policy against using agency RNs. The DON was unable to provide coverage every day, and the facility's staffing records and PBJ data reflected the absence of RN hours during the specified periods. The facility's policy stated the requirement for sufficient nursing staff, including RN coverage, but this was not met until the recent hiring of a weekend RN supervisor.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinent care for two residents. In the first instance, a CNA provided incontinent care to a female resident with moderate cognitive impairment, neurogenic bladder, and cerebral palsy. The CNA did not change gloves after cleaning the resident's perineal area and before applying barrier cream and a clean brief. Additionally, the CNA failed to perform hand hygiene between glove changes, only sanitizing hands at the end of the procedure. The CNA acknowledged awareness of the correct protocol but attributed the lapse to nervousness. In the second instance, another CNA provided incontinence care to a female resident with Alzheimer's disease and chronic kidney disease, who was always incontinent of bladder and bowel. The CNA wore the same gloves throughout the entire procedure, including after removing the soiled brief, cleaning the resident, and applying a clean brief. The CNA also touched clean linens, the bed controller, and the resident's pillow while still wearing the same gloves. The CNA admitted that gloves should have been changed and hand hygiene performed when transitioning from dirty to clean tasks. Interviews with the DON confirmed that staff are expected to change gloves and perform hand hygiene at appropriate times during care, and that failure to do so could place residents at risk for infection. Review of facility policy supported these expectations, stating that hand hygiene is required before donning and after doffing gloves, and that glove use does not replace hand hygiene. Skills checklists and training records were referenced, but documentation for one CNA was not available at the time of the survey.
Failure to Provide Proper Perineal Care and Infection Control During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was always incontinent of bowel and bladder and had diagnoses including Alzheimer's disease and chronic kidney disease. During observed incontinence care, the CNA did not follow the correct procedure for cleaning the perineal area, specifically failing to clean the labia first and not moving from the inside outward to the thighs as required by facility policy. The CNA also touched clean items and the resident's environment with contaminated gloves, further deviating from proper infection control practices. The resident's care plan required checking for incontinence every two hours and as needed, and the facility's policy specified the correct technique for perineal care. The CNA acknowledged the error during an interview, and the Director of Nursing confirmed that staff are trained and skills-checked annually on proper incontinent care. The failure to follow established procedures was directly observed and confirmed through interviews and record review.
Failure to Maintain Cleanliness of Stove Burner Drip Tray
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food service safety standards in the kitchen by not ensuring the stove burner drip tray was emptied and cleaned. During an inspection, the drip tray was found to be covered with food particles and thickened dark brown and black sticky substances. The Dietary Manager confirmed that the evening cook was responsible for cleaning the tray after supper but had not done so, and acknowledged the presence of food debris such as okra pieces. Facility policy requires the range and grill to be kept clean to minimize food hazards, but this standard was not met in this instance.
Failure to Document Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure all necessary documentation of discharge was in the medical record for four residents reviewed for discharge. This deficiency involved Residents #5, #6, #7, and #8, who were discharged without completed discharge summaries. The absence of these summaries could place residents at risk for not receiving care and services to meet their needs upon discharge. Resident #5, a female with dementia, dysphagia, and a cognitive communication deficit, was discharged to another facility without a discharge assessment or summary. Similarly, Resident #6, who had hydrocephalus, epilepsy, and intellectual disabilities, was discharged to a skilled nursing facility without a completed discharge summary. Interviews revealed that there was confusion among staff regarding who was responsible for completing the discharge summaries, with some believing it was the social worker's responsibility, while others thought it was the charge nurse's duty. Resident #7, who had heart failure and diabetes, was discharged to the community without a discharge summary, and Resident #8, with multiple diagnoses including orthopedic aftercare and chronic kidney disease, was discharged home with hospice care without the necessary documentation. The facility's policy required a discharge summary to include a comprehensive recapitulation of the resident's stay and a final summary of their status at discharge. However, interviews with staff, including the Administrator and DON, revealed a lack of clarity and training on discharge planning and documentation responsibilities, contributing to the deficiency.
Inadequate Documentation of PRN Pain Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate documentation and administration of PRN pain medications for four residents. The records for these residents showed discrepancies between the controlled drug records and the Medication Administration Records (MAR), indicating that medications were signed out but not documented as administered. This inconsistency was observed for multiple residents, including those with conditions such as diabetes, neuropathy, cancer, and chronic lung disease, who were receiving narcotic pain medications like hydrocodone-acetaminophen and oxycodone. Interviews with the Licensed Vocational Nurses (LVNs) revealed that they were not consistently signing out medications at the time of administration, leading to potential inaccuracies in drug reconciliation. LVN A admitted to signing out medications after administration and not updating the MAR promptly, which could result in residents receiving medications too soon or not at all. LVN C acknowledged that the current practice did not reflect an accurate picture of medication administration, and LVN B confirmed the expectation to document on both the narcotic drug sheet and the MAR at the time of administration. The Director of Nursing (DON) and the Administrator recognized the documentation issues after they were highlighted by the surveyor. The facility's policy on controlled substances requires accurate accountability of all controlled drugs, including immediate documentation on the accountability record and MAR. The failure to adhere to this policy could lead to missed doses, inaccurate records, and potential drug diversion, as noted by the DON.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gainesville Convalescent Center | 1.8 mi | ★★★★★ | 18 | 0 |
| Pecan Tree Rehab And Healthcare Center | 2.1 mi | ★★★★★ | 13 | 2 |
| Renaissance Care Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Whitesboro Health And Rehabilitation Center | 15.1 mi | ★★★★★ | 5 | 1 |
| Cedar Ridge Rehabilitation And Healthcare Center | 20 mi | ★★★★★ | 11 | 0 |
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