Inspection·June 25, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in accordance with State and Federal laws in locked compartments for 1 (600 hall cart) of 1 medication carts reviewed for medication storage. The facility failed to lock the medication cart on hall 600. This failure could place residents at risk for obtaining medications not prescribed to them and experiencing adverse reactions. Findings included: During an observation on 06/25/24 at 9:54 AM the medication cart in hall 600 was unlocked. All three drawers were easily opened and full of what looked like topical medications. A resident was awake and seated in his wheelchair in his room in line of sight of the medication cart. No staff members were in sight. During an interview and observation on 06/25/24 at 9:55 AM CNA A opened the top drawer of the 600 hall cart and stated if a medication cart was left unlocked someone could take medications, either residents or staff, and it would be bad for that to happen. During an observation on 06/25/24 at 10:02 AM of 2 nurses, Wound care nurse and RN B, coming back to the medication cart on hall 600 which had been left unlocked and abandoned for almost 10 minutes. During an interview and observation on 06/25/24 at 10:03 AM the Wound Care nurse stated she was a nurse practitioner who worked at the facility as their wound care nurse. The Wound Care nurse opened unlocked drawer of the 600 hall cart. The Wound Care nurse stated the cart was unlocked but it only held medications that were for topical wounds only. She stated the cart was normally locked and a possible negative outcome would be a resident could get into the supplies and take them. During an interview on 06/25/24 at 10:05 AM RN B Charge Nurse stated that the medication cart is normally locked. He stated that if a medication cart is not locked that someone could get into the cart and get things that are not theirs and a poor outcome could be a result. Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455989 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)