Avir at Pecos

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 5 residents reviewed for care plans. (Resident #1, and #2)The facility failed to ensure Resident #1's care plan included fall precautions. The facility failed to ensure Resident #2's care plan included his medical diagnoses, conditions, and special diet order. This failure had the potential to affect residents by placing them at risk for unmet care needs.

Inspectors wroteBased on observation, interviews and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained.-The facility failed to monitor and track performance of the black debris presence in the 300-hall shower room. The failure could place residents within the facility at risk for potential illness. An observation was made on 07/21/2026 at 3:05 PM in the 300-hall shower room of the inner bottom corners of the shower with white paste that was open with black debris underneath. Record review of the Nursing Facility's Quality Assessment and Performance Improvement Plan 2026, dated 06/2026, read in part under Environmental Rounds: Monitored by Administrator/Maintenance. [...]

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 3 days of 30 days reviewed for nursing services. The facility failed to have a registered nurse working on [DATE], [DATE], and [DATE]. This failure could place residents at risk of not receiving advanced nursing skill of a registered nurse.

Inspectors wroteBased on interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 facility reviewed for dignity.-The facility failed to maintain a working air conditioner in the facility van impeding the residents from being able to be taken out into the comunity to do activities. This failure could place residents at risk of diminished quality of life and compromise residents' dignity.

Inspectors wroteBased on observation and interview the facility failed to post in a location available for all residents, contact information including telephone numbers of the Long-Term Care Ombudsman program for the facility's postings for 53 residents reviewed for resident rights. The facility's single Ombudsman Program sign was posted on a posterboard on a sticker with small print in the hallway that led to the 200 hall and was not viewable to residents. This failure could place residents at risk of not having access to signs informing them of their rights and resident advocacy groups.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents had the right to a safe, clean, comfortable and homelike environment, for 2 of 4 halls observed for environment. The facility failed to ensure the shower room in the 300 hall was clean and free from black particles on the floor of the shower. The facility failed to ensure that the shower room in the memory care unit was free from exposed piping under the sink. The facility failed to ensure that four resident rooms were free from exposed piping under the sink. The facility failed to ensure that one resident room did not have a closet door off its hinge. This failure could place residents, who resided on the 300 and memory care unit, at risk for injury due to exposed piping and missing tiles and decrease in quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 7 residents reviewed for care plans. (Resident #4, Resident#37 and #49)The facility failed to ensure Resident #4's care plan included ADLs. The facility failed to ensure Resident #49's care plan addressed smoking,The facility failed to ensure Resident # 37's care plan addressed oxygen use This failure had the potential to affect residents by placing them at risk for unmet care needs. Record review of Resident #37's admission Record dated 05/12/2026 revealed a [AGE] year-old male with admission date 04/22/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 1 of 2 shower rooms reviewed for accidents.-The facility failed to properly store/dispose razors in the community shower room in the 300-hallway on 5/12/26. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the resident was offered sufficient fluid intake to maintain proper hydration and health for 3 (Resident #23, #27, #33) of 3 residents reviewed for access to hydration. The facility failed to ensure staff provided access to hydration and provide fresh water and ice at bedside for Residents (#23, #27, and #33) .This deficient practice could place residents at risk of being dehydrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Residents #37, Resident #39 and #49) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was posted on the doorways of Resident #37, Resident #39 and Resident #49 to ensure smoking was prohibited. This failure could place residents at risk of This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Resident #37Record review of Resident #37's admission Record dated 05/12/2026 revealed a [AGE] year-old male with admission date 04/22/2026. [...]

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 4 medication carts (200-hall) viewed for pharmacy services.-The facility failed to maintain a locked medication cart in the 200-hallway on 5/12/26. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

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.-The facility failed to label food items in the refrigerator and in the freezer on 5/12/2026 -The facility failed to keep containers of food in the refrigerator free of dried drippings on 5/12/2026-The facility failed to keep lids of containers free of dust in the dried food storage area on 05/12/2026-The facility failed to ensure kitchen staff used hair nets properly on 05/13/26 and 05/14/26-The facility failed to keep overflowing garbage in a container away from clean dishes on 05/12/2026 These failures could place residents at risk of food-borne illnesses from cross-contaminated food and beverages.

Inspectors wroteBased on interview and record review the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies. The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive. This failure could affect all residents and result in quality deficiencies not being recognized and corrected.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was to be gathered and analyzed, and plans of action were to be developed, implemented, and evaluated to address adverse events related to potential deficient practice for 1 of 1 QAPI programs reviewed. The facility failed to conduct at least one performance improvement project (PIP) annually that focused on high risk or problem prone areas identified by the facility, through data collection and analysis. This failure could place residents of the facility at risk of the facility not developing, monitoring and implementing corrective actions for identified areas of improvement.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an injury of unknown source, immediately, but not later than 2 hours after the allegation was made, to other officials in accordance with State law, including to the State Survey Agency for 2 of 5 residents reviewed for falls. (Residents #7, #44)The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist. The facility failed to report to the State Survey Agency when Resident #44 sustained an unwitnessed bruise to right eye and a laceration to forehead and was unable to state how the injury occurred on 05/09/2026. The facility failed to report when a pipe burst, and the sprinkler system malfunctioned on 01/27/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to show evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 of 5 residents (Resident #7 and #44) reviewed for injuries of unknown origin. The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist. The facility failed to investigate an injury of unknown origin for Resident #44 resulting in bruising around the right eye and a laceration above the right eyebrow on 05/09/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 7 (Resident #4) residents reviewed for base line care plans. The facility failed to develop Resident #4's baseline care plan within 48 hours of admission. This failure placed newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene, for 1 Resident of 7 residents (Resident #4) reviewed for activities of daily living. The facility failed to provide Resident #4 with nail care on 05/12/2026. This failure could place residents at risk for embarrassment, injury, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for 2 resident 12 residents (Resident #7 and Resident #49) reviewed for foot care. The facility staff CNAs and licensed nurses failed to provide foot care for Resident #7 and Resident # 49 on 05/12/2026This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life.

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 1 of 2 shower rooms reviewed for infection control. -The facility failed to ensure plastic urinal that was hanging in the community shower room/ bathroom in the 300 hall was not full of urine. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, for 1 of 8 staff (DON) reviewed for abuse, neglect exploitation training. The facility failed to ensure the DON had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 1 of 8 staff (the DON) reviewed for training, in that:The facility failed to ensure infection prevention and control training was provided to the DON.This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with reasonable accommodation of needs and preferences, including ensuring the call light was within reach to request assistance, for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident# 1 had the call light within reach. This failure placed Resident #1 at risk for unmet needs, delayed assistance, increased fall risk, and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 water dispenser reviewed for physical environment. The facility failed to ensure:A. The water dispenser that was used for the residents was clean and not soiled. B. The floors in the area where the water dispenser was housed were free of dirt. C. The floor tiles in the area where the water dispenser was housed were free of cracks. This failure could affect the residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observations, interviews, 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 food was stored in a manner that was not open to the air. 3. The facility failed to remove potatoes in the dry storage when they were beginning to show signs of rot. 4. The facility failed to ensure expired food items were discarded by the expiration date. 5. The facility failed to maintain cleanliness in the kitchen. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain all mechanical and electrical quipment in safe operating condition for 1 of 1 kitchen reviewed for kitchen sanitation. The spray nozzle above the rinsing sink in the dishwashing room leaked, and the oven did not work. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness or undercooked food.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #8) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #8 was free of abuse on 03/20/25 when Resident #8 was hit on the arm and shoulder by CNA C. This failure was determined to be Past Non-Compliance (PNC). The non-compliance began on 03/20/25 and ended on 03/21/25. The noncompliance was corrected by the facility before the survey began on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who receive medication or feeding through a gastrostomy tube receive the appropriate treatment to prevent complications for 1 of 1 resident (Resident 44) reviewed for percutaneous endoscopic gastrostomy (PEG) feeding tube ( A PEG is a tube that is inserted through the abdominal wall and into the stomach and used to administer nutrition). The facility failed to ensure CNA A did not lower the head of Resident #44's bed flat while the PEG tube feeding pump was still infusing the formula, during personal care. This failure could place residents of aspiration.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 1 of 3 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure RN coverage on 10/12/2024 and 10/26/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

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 one (Resident #44) of two residents reviewed for incontinent care in that; CNA A failed to wash or sanitize her hands between glove changes while assisting Resident #44. 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 ensure adequate supervision and assistance devices was provided for 1 of 3 residents reviewed for transfers (Resident #1). The facility failed to assess Resident #1 for safe transfer practices as she was non-weight bearing. This deficient practice has the potential to affect residents in the building who required extensive assistance which could result in residents having pain, falls or injuries.

Inspectors wroteBased on observation, interview and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: 1. The facility failed to label and date food items. 2. The facility failed to discard expired food items. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 14 residents (Resident #21, Resident # 35) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #21 prior to administering Zoloft, an antidepressant used to treat depression. [...]

Inspectors wroteBased on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 92 days in July 2023 - September 2023 The facility had no Registered Nurse coverage on dates 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. This failure could affect all residents and put them at risk of their care not being overseen properly.

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 medication rooms had an expired Tuberculin (TB) vial medication in the refrigerator. 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 ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts ( Hall 100 nurse medication cart) reviewed for medication storage and failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure the hall 100 nurse medication cart did not contain expired insulin pens and had open dates after they were put into use. [...]

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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #43) reviewed for infection control. CNA A failed to wash hands or use hand sanitizer between glove changes during incontinent care while assisting Resident #43. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for 2 of 15 (Resident #1 and Resident #2) residents reviewed for infection control. Three facility staff (MT, HA A, and HSKG) failed to follow the facility's infection prevention protocol for COVID-19 by failing to wear appropriate PPE. MT entered the hot zone with N95 mask and no other PPE. HA A did not wear appropriate PPE for the warm unit. HSKG did not wear appropriate PPE going into hot zone and shower room. Shower room was not sanitized after Resident #1, who was on isolation for exposure to COVID-19. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19.

Inspectors wroteBased on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 2 residents (Residents #3) reviewed for a notification of a change of condition, in that: Resident #3 was known to be covid-19 negative but roomed with Resident #4 who was known to be covid-19 positive. Facility failed to report to Physician that his patient Resident #3 was being roomed with a covid positive Resident #4. This deficient practice could place residents at risks of not having the physician contacted when they have a change of condition, and it could result in delay of medical treatment and hospitalization.