Health inspection·November 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 12 (Residents #1, #2, and #3) residents reviewed for comprehensive care plans.The facility failed to have a care plan for Resident #1's dialysis, diabetic care, glaucoma, seizures, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. The facility failed to have a care plan for Resident #2's mental health and behavioral issues, pain, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin impairment, incontinence, or vaccination status. The facility failed to have a care plan for Resident #3's code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid, hypertension, diabetic care, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. These failures could place residents at risk for not receiving appropriate care and supervision.Findings included: Resident #1Review of Resident #1's admission Record, dated 11/17/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dialysis, epilepsy, pain, diabetes, history of foot ulcers, depression, glaucoma, and heart failure.Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed:She had impaired vision.She had a BIMS Score of 15 of 15 (indicating she was cognitively intact).She scored a 1 of 27 on her depression screening (is a scale that used to measure the severity of the depression.She used a wheelchair for mobility.She had a therapeutic diet.She was at risk for developing skin sores.She had diabetic foot sores.She received insulin injections 7 of 7 days. She was on an anti-anxiety medication, an antidepressant medication, an anticoagulant, needed hypoglycemic agents, and was on an anticonvulsant.She received at least 2 days of therapy.Review of Resident #1's Order Summary Report, dated 11/17/25 revealed orders:Receive Dialysis services Tuesday Thursday - Saturday dated 7/15/25Was on a fluid restriction dated 7/15/25Preventative care to left foot dated 11/8/25Blood pressure medications Amlodipine, Clonidine, Lostartan Potassium, and Metoprolol with hold parameters. Start date 7/16/25.Antianxiety medication Buspar start date 7/15/25Blood thinner Apixaban start date 7/13/25The neuropathy medication Gabapentin, start date 7/15/25Glucagon shot as needed for low blood sugar dated 7/15/25Short acting Insulin sliding scale (amount varies depending on blood sugar) dated 9/7/25.Long-acting Insulin dated 7/23/25Antiseizure medication LevetiracetamAnti-depressant medication Mirtazapine, Trazadone, and Sertraline dated 7/15/25Glaucoma eye drops dated 7/13/25Migraine medication Rimegepant Sulfate dated 7/15/25Kidney medication Sevelamer Carbonate dated 7/13/25. Review of Resident #1's care plan initiated 7/20/25 revealed care plans for Resident #1's code status, allergy to latex, and personal care/activity preferences. There was no care plan for dialysis including shunt monitoring and care or fluid restriction; diabetic Page 1 of 4 676100 676100 11/19/2025 Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care including blood sugar checks, dietary restrictions or insulin needs; glaucoma including adaptations for vision; seizures including medications, monitoring labs, or safety precautions; depression and anxiety including medications, side effects and behavior monitoring/ follow up; diabetic foot ulcers including enhanced barrier precautions, wound care, barriers to wound healing; blood pressure monitoring including frequency; ADL assistance needs; risk of complications, and vaccine status. Resident #2Review of Resident #2's admission Record, dated 11/14/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, pain, dementia with behaviors, hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream), malnutrition, anxiety, heart problems, arthritis, gout (excessive build-up of uric acid in a joint, frequently the foot, causing pain), closed fracture of the neck bones, and hospice care. Review of Resident #2's admission MDS dated [DATE] showed the following Care Area Assessments: Cognitive Loss/Dementia, Communication, Urinary Continence, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcers, and Psychotropic Drug Use. All areas had a care planning decision dated 7/28/25. Review of Resident #2's Quarterly MDS Assessment, dated 8/8/25 revealed:He had a BIMS score of 1 of 15 (indicating severe cognitive impairments).He wandered 1 to 3 days of 7 in the previous 7 days.He used a wheelchair for mobility.He needed substantial or maximum assistance for toileting.He needed partial to moderate assistance for hygiene, bathing, and dressing.He had a catheter and was always incontinent of bowel. He had a prognosis of less than 6 months to live.He had 1 fall with minor injury since the previous assessment.He was on a mechanically altered diet.He was at risk for pressure sores.He needed injections for 3 of 7 days and was on an anti-anxiety medication, an anticoagulant, an opiate medication, an antiplatelet medication, and an anticonvulsant. He received Hospice care.He received at least 2 days of therapy.Review of Resident #2's Order Summary Report, dated 11/14/25, revealed orders:Hospice Care dated 7/17/25Divalprex Sodium for Dementia with other behavior disturbanceAn antianxiety medication Lorazepam dated 9/11/25Blood pressure medications Metoprolol Tartrate, Midodrine with with hold parameters. Dated 7/17/25Pain Medication Morphine Sulfate and Tramadol dated 7/17/25Nicotine Patch dated 7/17/25Arthritis medication Sulfasalazine dated 7/17/25.Review of Resident #2's Care Plan revised 7/17/25 revealed care plans for code status, allergies to Penicillin alcohol and beef, Personalized Care preference. A care plan addressing fall prevention was developed 11/10/25. There was no care plan addressing Resident #2's behaviors, pain, anxiety, high blood pressure, Hospice Services, ADL needs, communication, cognitive status; risk of complications; nutritional status, risk to skin impairment, incontinence, or vaccination status. Resident #3Review of Resident #3's admission Record, dated 11/14/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, weakness, history of falls, high cholesterol, anxiety, closed fractures, anemia, low thyroid, diabetes, depression, cataract, high blood pressure, paralysis on one side, and kidney disease. Review of Resident #3's Quarterly MDS Assessment, dated 10/23/25, revealed:She had a BIMS score of 12 of 15 (indicating she was moderately cognitively impaired).She had range of motion impairment on one upper extremity.She used a wheelchair for mobility.She needed moderate assistance for toileting, showering, and dressing. She received as-needed pain medication in the 5 days prior to the assessment and reported occasionally experiencing pain. She rated the pain at 5 out of 10.She was on a mechanically altered and therapeutic diet.She was at risk for pressure sores. She received insulin injections for 7 of 7 days, was on an antidepressant and a hypoglycemic.Review of Resident #3's Order Summary Report, dated 11/14/25, revealed orders:Fluid restriction, dated 7/19/25.Oxygen orders (oxygen at 2 liters via nasal cannula as needed for shortness of breath or oxygen saturation less than 90 percent. Do not exceed 4 liters without physician approval if 676100 Page 2 of 4 676100 11/19/2025 Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident was on continuous oxygen), dated 7/30/25.Antidepressants Citalopram and Trazadone.Short Acting Insulin sliding scale, dated 7/18/25.Hypertension medications Isosorbide Mononitrate, Midodine with hold parameters.Low thyroid medication Levothyroxine.Kidney Disease medication Sevelamer Carbonate.Pain Medication Tramadol.Review of Resident #3's Care Plan, initiated 7/23/25 revealed a care plan for Personalized Care.There was no care plans regarding Resident #3's code status, depression, Kidney disease, pain, dietary or fluid restriction, low thyroid, hypertension, diabetic needs, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. Interview on 11/19/25 at 11:39 a.m. MDS Coordinator D stated she had worked at the facility for two months. She stated her assessment usually was what was required by the MDS Assessment. MDS Coordinator D stated the care plans were a group effort. MDS Coordinator D stated the care plans defined how the facility took care of the resident, whatever procedures were needed. She stated things on the care plan included fall risks, behaviors, and diseases the resident might have that required special attention. MDS Coordinator D stated the facility did not have anyone in the building to do care plans for a while so they were lacking and MDS Coordinator D was trying to get them up to par. MDS Coordinator stated she was working on care plans and they were a work in progress. The MDS Coordinator stated code status, behaviors and dialysis were all things she would expect to see on a care plan.Interview on 11/19/25 at 11:46 a.m. MDS Coordinator E stated care plans needed to be individualized to the resident. MDS Coordinator E stated she was new to the facility so she could not explain the process. MDS Coordinator E said to develop a care plan she would go through the chart looking for a history of falls, any of the Care Assessment Areas, any kind of psychiatric issues, and high-risk medications. MDS Coordinator E said the care plan was usually done right after the MDS Assessment. MDS Coordinator E said the facility was without an MDS Person in the facility for three months and the MDS Assessments were completed remotely by another MDS Coordinator. MDS Coordinator E stated the facility had some areas they could improve on for the care plans. MDS Coordinator E stated the care plan should be interdisciplinary, but no one actually entered the care plan so the MDS Coordinator entered the care plan in as quickly as they could. The MDS Coordinator stated members of the Interdisciplinary Team had the ability to enter their own areas care plan. MDS Coordinator E stated all the management staff had been at the facility for less than 6 months so were new but were all experienced in their position so they would get the care plans corrected.Interview on 11/19/25 at 12:08 p.m. the DON stated she thought there was probably room for improvement with care plans because the facility switched people several times. The DON stated she expected resident risk, elopement risk/attempts, falls or fall risk, risks related to diagnosis or medications. The DON said she expected things that were individual to resident behavioral or other residents' needs like a specialized piece of equipment. The DON stated she saw some of the care plans and thought there was room for improvement. The DON stated she was at the facility for 6 weeks and the corporation brought in a new MDS person. The DON said that many of the residents' needs and expectations were also outlined in the physician orders so the staff would know their expectations. The DON said the facility had a lead CNA who made a paper cheat sheet that was not part of the official resident record that informed the other CNAs, including agency CNAs, what kind of care the residents needed.The Corporate RN was also present and said she expected acute issues like a new onset of a urinary tract infection or other change of condition be care planned. The Corporate RN stated care plans were a work in progress. The Corporate RN stated she started in mid-October, so she did not know what happened to the care plans. The Corporate RN said there was turnover with all management staff including the MDS Coordinator. The Corporate RN said their plan was to work on the care plan, but they had been kind of busy.Review of the facility's 676100 Page 3 of 4 676100 11/19/2025 Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904

F 0656 Level of Harm - Minimal harm or potential for actual harm policy and procedure on Care Planning - Interdisciplinary Team, updated 12/2024, revealed:The interdisciplinary team is responsible for the development of resident care plans. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Residents Affected - Some 676100 Page 4 of 4