Avir at Pampa

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 (Hall 100 and Hall 200) of 2 medication carts, and 1 of 1 OTC closet. -two bottles of Calcium Supplement with expiration dates that were not legible in the OTC closet.-one loose pill was in the bottom of Medication cart #1. These failures could place residents at risk for not receiving the intended therapeutic action of the medication. Findings Included:During an observation on 01/26/2026 at 9:59 AM one loose pill (unidentified) was discovered in the bottom of medication cart #1's drawer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, pantry and kitchen items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses. Findings Included:During an observation of the pantry on 01/26/26 at 9:39 a.m. revealed the following:1. (1) clear container that contained what looked like rice, no lid on container, no label or date.2. (2) boxes of packets of jelly, no label or date.3. 1) container of sugar, lid not sealed.4. (1) box of potatoes, no label or date. During an observation of the freezer on 01/26/26 at 9:43 a.m. revealed the following:1. (1) box of frozen meat, no label or date.2. [...]

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 communication diseases and infections for 4 (Resident #6, #13, #30 and Resident #42) of 12 residents reviewed for infection control. The facility failed to develop and maintain an infection prevention and control program as attested to by: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #2) of 5 residents reviewed for unnecessary drugs. The facility failed to ensure a gradual dose reduction of one of Resident #2's psychotropic medications was attempted or contraindicated from April 2025 to January 2026. This failure could place residents at risk of being overmedicated. Findings Included:Record review of Resident #2's admission record dated 01/28/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease with early onset and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were to be administered consistent with professional standards of practice and physicians orders for 1 of 12 residents (Resident #11) reviewed for physician orders. The facility failed to follow physician orders for completing central line care for resident #11. This failure could place residents at risk for not receiving needed care to maintain optimum health and injury and/or deterioration in their condition. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized medical records for 1 (Resident #11) of 12 residents reviewed for medical records. The facility failed to ensure accurate and complete medical records in that:-PICC line dressing was dated 01/19/2026 with no Haloguard in place over insertion site.-Resident #11's TAR revealed that there was no documented dressing change on 01/19/2026.-Resident #11's TAR indicated that a dressing change took place on 01/25/2026. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the results of an investigation in accordance with State Law within 5 working days of the incident for 1 of 5 incidents (Resident #1) reviewed for reporting. -The Administrator failed to report the results of an investigation within 5 days to the State Survey Agency. This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 employees (CNA A, LVN B and RNRS C) reviewed for infection control. The facility failed to ensure CNA A, LVN B, and RNRS C practiced proper hand hygiene while serving and assisting residents during the lunch meal on 2/5/25. This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility for 1 of 1 resident council. The facility failed to ensure feedback and concerns expressed in the resident council meetings were addressed by the facility staff for the past seven months. This deficient practice could affect the residents who attended resident council meetings for the past seven months and place them at-risk to decrease quality of life and contribute to grievances not being resolved.

Inspectors wroteBased on interviews, and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 33 days in the months of April, May, June July and October, 2024. The facility did not have an RN in the facility for 8 consecutive hours on the following dates: April 4, 5, 6, 7, 10, 13, 14, 20, 21, 27, and 28th of 2024. May 4, 5, 11, 12, 18, 19, 25, 2 6, and 27th of 2024. June 1, 2, 8, .9. 15, 16., 22, .23, .29. and 30th of 2024. July 13 and 14 of 2024. The date of October 11, 2024 only had RN coverage for 5.63 hours. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore a hair restraint while in the kitchen. B. Ensure stored food was properly labeled, dated and covered. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 2 of 16 residents (Resident # 3, #13) reviewed for accommodation of needs. Resident #3 and #13's call light were not within reach . This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (RN F) of 13 staff reviewed for abuse policies. The facility failed to make sure that a potential employee who would be working with residents directly was free of criminal charges. This failure could place residents of the facility at risk of abuse or neglect at the hands of an employee with a documented history of these types of behaviors. Findings Included: Record review of RN F's employee file revealed a hire date of 7/4/2024 and an Employee Misconduct Registry (EMR) with a date of 7/9/2024. During an interview on 10/30/24 at 11:21AM, HRD stated that RN F was supposed to start later in the month but started on July 4, 2024. [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 1 of 3 medication areas (medication room) reviewed for medication storage. The facility medication room contained 3 prescription medications that were expired. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff for abuse, neglect, and exploitation for 4 (SLP, CNA B, CNA C, and LVN D) of 13 employees evaluated for the required trainings. SLP was hired 7-11-2020 and no training had been provided on Abuse, Neglect, and Exploitation in the last 12 months. CNA B was hired 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. CNA C was hired 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. LVN D was hired 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care and prevent injuries. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement an effective discharge planning process for 1 of 15 residents (Resident #1) reviewed for care plans. The facility failed to prepare Resident #1 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. This failure placed the resident at risk of readmission and his needs not being met.