Health inspection·February 9, 2026

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings included:Record review of Resident #1's face sheet undated, accessed on 02/8/2026 reflected a [AGE] year-old male, admitted [DATE]. Resident #1 had diagnoses which included: hemiparesis following cerebral infarction affecting right dominant side (paralysis on right side after a stroke), Schizoaffective Disorder (condition combining schizophrenia such as hallucinations and disorganized thinking, and mood disorder like bipolar or depression), Unspecified Dementia, mild, with psychotic disturbance (early-stage cognitive decline with symptoms such as hallucinations, delusions or paranoia), Other psychotic disorder not due to substance or known physiological condition (hallucinations, or delusions that do not meet schizophrenia, bipolar, or other specific disorders), Other speech and language deficits following cerebral infarction (wide range of speech deficits beyond aphasia), Cerebral Infarction (type of stroke caused by blockage in a brain artery resulting in oxygen deprivation and tissue death), Anxiety disorder (persistent, excessive, irrational fear or worry that interferes with daily life), Functional Quadriplegia (permanent immobility and inability to care for oneself resulting from advanced frailty or end-stage chronic illness), Depression (persistent sadness, loss of interest in activities, fatigue, and physical pain lasting two weeks), other symbolic dysfunctions (Have impairments that affect the person's ability to use and understand symbols, language, and perform related tasks). Record review of Resident #1's Care Plan, dated 01/20/2026, revealed interventions were to administer psychotropic medications as ordered by the physician. The care plan further revealed GDR was dated 12/17/25. Record review of Resident #1's clinical physician's orders, dated 12/17/25, revealed Olanzapine 2.5 MG tablet ordered by the PHY directed to give 1.25 mg by mouth two times a day related to schizoaffective disorder. Record review of Resident #1's Consent for Antipsychotic or Neuroleptic Medication Treatment, dated 11/27/25, revealed the PHY was treating Resident #1's psychiatric condition: F25.9 (schizoaffective disorder). Olanzapine 2.5 MG PO BID was proposed for the course of therapy. Record review of Resident #1's Medical Diagnosis undated, accessed on 02/08/2026 revealed code F25.9 Schizoaffective Disorder, Unspecified dated 5/16/25. Record review of Resident #1's electronic health records accessed on 02/08/2026 reflecting no documentation diagnosing Resident #1 with Schizoaffective Disorder, Unspecified (F25.9). During an interview on 2/07/2026 at 3:44 p.m., LVN A stated when she first started working with Resident #1 in July of 2025, he would not come out of his room at all. LVN A stated Resident #1 gradually would Residents Affected - Few Page 1 of 2 675522 675522 02/09/2026 Avir at Monahans 1200 W 15th St Monahans, TX 79756

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few come out for meals but wanted to go back to his room right after. LVN A stated now Resident #1 comes out for meals and sits out in the lobby with the other residents during activities for a little while. LVN A stated Resident #1 would not interact but was better than before. During an attempted interview on 02/07/2026 at 3:39 p.m., Resident #1 stated everything is fine and refused to answer any questions. During an attempted interview on 02/07/2026 at 5:13 p.m., Resident #1 stated to leave him alone. During an attempted interview on 02/08/2026 at 10:20 a.m., Resident #1 would not speak or answer any questions. During an observation on 2/08/2026 at 4:40 p.m., Resident #1 was sitting in his wheelchair with other residents in the common area watching TV with no behavior or concerns noted. During an interview on 2/08/2026 at 7:54 p.m., ADON stated Resident #1 was doing better and being a little more active and coming out of his room. ADON stated Resident #1 had less aggression regarding his care. In an interview on 2/09/2026 at 1:10 p.m., DON stated the facility does not have a comprehensive assessment diagnosing Resident #1 with schizoaffective disorder. DON stated the failure had no negative resident effects. She stated they had completed a GDR, and he had done well with that and felt his course of treatment was effective and appropriate. During an interview on 2/09/2026 at 2:35 p.m., PHY stated Resident #1 had sleep and depression issues and last year Resident #1 was having more issues on a psychosis phase. PHY stated he had staff document information about the resident and Resident #1 had paranoid behaviors and episodes of hallucinations and agitation for several weeks. PHY stated he did not use a comprehensive assessment and just went by symptoms. PHY stated he knew Resident #1, and he definitely had schizoaffective disorder, and he stands by his diagnosis. PHY stated he would get the documentation and send it to the facility. In an interview on 2/09/2026 at 4:00 p.m., ADM stated she had known Resident #1 since approximately 2020. ADM stated Resident #1 used to holler and scream. She stated he would yell if he was removed from his chair. ADM stated the facility did not have a comprehensive assessment diagnosing Resident #1 with schizoaffective disorder. ADM stated she believed his treatment helped him and was appropriate care because he was more active, would come out of his room, and did not scream anymore. ADM did not state how not having the comprehensive assessment could affect a resident.Record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, reflected, The comprehensive, person-centered care plan: .e. reflects currently reorganized standards of practice from problem areas and conditions. 675522 Page 2 of 2