Avir at Fredericksburg

In the surveyor’s words

From the most serious findings on record at Avir at Fredericksburg, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760May 27, 2026

  Based on interviews and record reviews, the facility failed to ensure that Resident #1 was free of significant medication errors for 1 of 3 residents (Resident #1) reviewed for medication errors. - LVN A administered Resident #2's medications to Resident #1. Resident #1 had a change of condition (slow respirations and low oxygen saturation levels) and was sent to the hospital via 911 EMS where she was diagnosed and treated for opioid overdose.- LVN A did not administer Resident #2's daily 4:00 PM prescriptions. A past non-compliance Immediate Jeopardy (IJ) was identified at 1:50 p.m. on 5/27/2026. The immediacy began on 5/24/2026 and ended on 5/25/2026. […]

• Immediate jeopardy, isolatedF684Mar 26, 2023

  Based on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that: The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on [DATE] and [DATE], Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. […]

• No harm, potential for more than minimal, widespreadF865Feb 8, 2022

  Based on interview and record review the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program that includes reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility failed to provide documentation that demonstrated evidence of their ongoing QAPI program. This failure could place residents at risk for quality deficiencies being unidentified with no appropriate plans or actions to be developed or implemented. […]

• No harm, potential for more than minimal, widespreadF868Feb 8, 2022

  Based on interviews and record review, the facility failed to maintain an ongoing quality assessment and assurance (QAA) committee that includes at minimum, the director of nursing services, the Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role; and meets at least quarterly for 4 of 4 quarterly meetings (January 2021, April 2021, July 2021, October 2021). […]

• No harm, potential for more than minimal, patternF604Jun 20, 2025

  Based on interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and that were not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #29) reviewed for freedom from physical and chemical restraints. The facility failed to ensure Resident #29 was free from physical restraint when nursing staff physically restrained her for medication administration on 06/02/25, 06/04/25, and 06/17/25. These deficient practices could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). […]