Federal inspectors cited Avir at Western Hills following a complaint inspection on May 27, 2026.
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The admission came during a May 27 complaint inspection at the 65th Avenue facility.
The resident, identified in inspection records only as Resident #60, was admitted to the 78-bed facility on May 22, 2026.
At that level, the standing orders were clear: notify the physician if blood sugar exceeded 400.
The resident at the center of the complaint, identified in inspection records only as Resident #1, had a therapy recommendation on file dated May 1, 2026.
One allegation of sexual abuse.
On May 7, 2026, a nurse documented that his edema had increased and applied Tubigrips, elastic compression sleeves, as a new form of treatment.
He said he asked to go out on pass, went to his girlfriend's house, and stayed the night when it got late.
Nobody caught it until a complaint triggered an inspection.
The resident had never had one.
The resident, identified in inspection records only as R58, had Alzheimer's disease and severe cognitive impairment.
That's what inspectors found at Aurora Valley Care during a complaint inspection on May 27, 2026.