Avir at Monahans

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 4 of 12 residents (Resident #2, Resident #4, Resident #5, Resident #10) reviewed for pharmacy services. The facility failed to ensure the hypertensive medication orders included adequate indications for its use to include parameters to administer or hold medications for Resident #2, Resident #4, Resident #5, and Resident #10. This failure could place the residents at risk of inadequate care and services.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 12 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #1. The facility failed to ensure the comprehensive care plans for Resident #1 and Resident #2 described the resident's goals for admission and desired outcomes. The facility failed to ensure the comprehensive care plan for Resident #2 described the resident's preference and potential for future discharge. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all services, as outlined by the comprehensive care plan, being provided meet professional standards for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was diagnosed by a practitioner using evidence-based criteria that meet professional standards of quality and lacked supporting documentation (comprehensive assessment) in the resident's medical record for a schizoaffective disorder diagnosis. This failure could place the residents at risk of not meeting their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that all services, as outlined by the comprehensive care plan, being provided or arranged by the facility met professional standards for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was diagnosed by a practitioner using evidence-based criteria that met professional standards of quality and lacked supporting documentation in the resident's medical record for schizoaffective disorder diagnosis. This failure could place residents at risk of physical and psychosocial harm by not following the clinical standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to ensure foods were properly stored, labeled and dated. The facility failed to dispose of spoiled food items properly. The facility failed to prevent possible cross contamination. The facility failed to ensure dietary staff used hair restraints properly. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 7 residents (Residents #5, #6, and #33) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan for Activities of Daily Living, Incontinence, Insulin, Psychotropic Medication, or Hospitalization. The facility failed to ensure Resident #6 had a care plan for Activities of Daily Living, Psychotropic Medications, Opiate Medications, and Hospice Care. The facility failed to ensure Resident #33 had a care plan for Activities, Psychotropic Medications, and Diuretic Use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 3 medication carts (Hall 100 and 200 nurse medication cart) and 1 out of 1 med room reviewed for medication storage. The facility failed to ensure the nurses cart #1 for 100 and 200 halls did not contain insulin, that were opened and not labeled with the open date. The medication room had an open vial of tuberculosis (a bacterial infection that affects the lungs and can spread to other organs) solution that was not labeled with an open date.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 5 staff (Medication Aide C) reviewed for infection control in that: -Medication Aide C did not sanitize or wash her hands before handling medication or in between administering medications to different residents. This failure could place residents at risk for infectious diseases. Findings Included: During an observation on 07/28/25 at 12:06 PM revealed Medication Aide C came out of a resident's room and proceeded to pour more medications without washing or sanitizing hands. Medication Aide C continued to not sanitize her hands in between the 12 residents she administered the med pass. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 2 of 3 residents reviewed for transfers (Resident #26 and #52). The facility failed to ensure staff locked the breaks of the mechanical lift (device used to assist in lifting a resident) during transfer for Resident #26. The facility failed to ensure staff completed gait belt transfer correctly for Resident #52. This deficient practice has the potential to affect residents in the building who required extensive assistance with proper transfers.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure the refrigerator door adequately closed and sealed in the kitchen on 07/27/2025. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. 2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 washing machine and 1 of 4 resident wheelchair brakes reviewed for essential equipment. 1. The facility did not provide necessary repairs for 1 industrial washing machines. 2. The facility failed to ensure Resident #1's wheelchair brakes were not broken These failures could place residents at risk of not having clean clothes to wear and place residents at risk of function mobility and injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 (Broken blinds), 2 warped tiles, 3 holes in the walls, 1 exit door missing sweep of 4 exit doors, and 1 of 1 maintenance log reviewed for environment. 1. The facility failed to ensure the blinds were not broken. 2. The facility failed to ensure floor tiles were not warped. 3. The facility failed to ensure there were not holes in hallway 3 and a hole in the hall leading to the back smoking patio/laundry room. 4. The facility failed to ensure the hallway 1 Exit door was not missing a sweep and created a seal on the mid-top side of the door to not expose the outside elements. 5. The facility staff failed to input broken items into the maintenance work order log. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. 1. The facility failed to ensure Hallway 1 did not smell of urine. 2. The facility failed to ensure Resident #2 did not have a dirty bed linens. These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #3) reviewed for accuracy of MDS assessment. The facility failed to ensure Resident #3's quarterly MDS, dated 01/2025, accurately reflected the residents' behaviors. This deficient practice could place residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 (Resident #3) reviewed for pharmacy services. The facility failed to record Tramadol-50 mg Schedule IV tablet was given to Resident #3 at 7:30 AM per physician orders in the narcotic logbook. This failure could place residents at risk for being over mediated which could result in medical complications and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control. 1. MA A touched Resident #3's pills with her bare hands during medication administration. 2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for the residents on the 300 Hall reviewed for resident rights in that: The facility failed to ensure resident's room hand sinks maintained functioning hot water. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 16 days in Quarter 2 2024 reviewed for Licensed Nursing coverage from January 2024, February 2024 reviewed for nursing services. The facility did not have the required 8 consecutive hours of RN coverage during the month of January 2024 (11 days) and February 2024 (5 days). This failure could place residents at risk for not having their nursing care and medical needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #4 and #17) of 12 residents reviewed for infection control. The facility failed to ensure: The facility failed to ensure CNAs A and B washed or sanitized their hands prior to putting on gloves and change their gloves after they became contaminated during incontinent care while assisting Resident #4. The facility failed to ensure CNA C changed her gloves after they became contaminated during incontinent care while assisting Resident # 17 This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms inspected for medication storage. The facility failed to ensure the medication room did not have an expired vial of Tuberculin (TB) medication in the refrigerator. (TB formula is used to test people for tuberculosis). This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for one (Treatment Cart) of 3 medication carts reviewed for drug storage. The facility failed to ensure the treatment cart was not left unlocked and unsupervised. This failure could place clients at risk for drug diversion or accidental ingestion.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of room change was received, including the reason the room was changed, for 2 (Residents #7 and #15) of 3 residents reviewed for notification of room change. -The facility failed to provide Resident #7 and/or their RP a written notice of a room change before the resident was moved. -The facility failed to provide Resident #15 and/or their RP a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings Included: Resident #7: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #15) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #15's bedroom entrance door and door to the restroom were not partially blocked by a dresser. This failure could place the resident at risk of decreased quality of life due to the lack of a well-maintained environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA K) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA K had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could place residents at risk for receiving care from someone unqualified to provide care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (12/20/2023) of 4 days reviewed for nurse staffing information. The facility failed to post the required staffing information for 12/20/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. This places residents at risk of receiving outdated foods.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 15 residents (Residents #13, #15, #16, #21, #26, #30, and #142) reviewed for care plans in that: 1. Resident #13 did not have a care plan to address cognitive ability or delirium, psychosocial well-being/ mood state, behavioral symptoms including the use of a wander guard, falls, nutritional status, or medication use including antidepressant, anticoagulant or diuretic use), diagnosis of seizures, anxiety, or stroke. 2. Resident #15 did not have a care plan for pain/neuropathy, presence of a pacemaker, intermittent explosive disorder, or wheelchair use. 3. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that 2 of 4 (Resident #3 and #142) residents reviewed for respiratory care was provided care consistent with professional standards of practice in that: Resident # 3's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy. Resident #142's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy. This deficient practice could affect residents who received oxygen treatments and result in respiratory infection. Record review of Record review of Resident #3's face sheet revealed admission date of 11/10/22 with diagnoses of Congestive Heart Failure, Chronic Kidney Disease, Diabetes Mellitus. She was [AGE] years of age. Record review of Resident #3's care plan dated 05/11/2023 failed to mention use of oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 2 of 8 residents (Resident #19 and Resident #25) reviewed for medication administration. The facility failed to ensure Resident #19 and Resident #25 received prescribed Senna-Docusate 8.6/50 mg (stimulant laxative/stool softener combination medication) verses administered Senna 8.6mg (stimulant laxative only). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 residents (Resident #19) reviewed for infection control. CNA A failed to wash her hands before or after incontinent care and did not change her gloves during incontinent care for Resident #19. This failure could place incontinent residents at risk for transmission of diseases and organisms.