Avir at Arbor Terrace: Care Plan Failures for PTSD Resident - TX
The resident, identified in inspection records as Resident #26, was mentally sharp. A cognitive assessment completed in February 2026 gave him a perfect score, meaning he understood his situation, his surroundings, and his treatment. He had been prescribed olanzapine, an antipsychotic, since November 2025. He had been on duloxetine, an antidepressant, since December 2025. The day before inspectors arrived, he was started on a second antidepressant, trazodone.
None of it was in his care plan. Neither was his PTSD diagnosis.
Federal inspectors visited Avir at Arbor Terrace on April 30, 2026, responding to a complaint. What they found was a care plan initiated in February 2025 that had never been updated to reflect months of psychiatric treatment for a resident whose conditions, by any measure, required careful, individualized attention.
The facility's interim director of nursing did not dispute the finding. She told inspectors that afternoon that medications and diagnoses are supposed to be care planned, and that a care plan that doesn't reflect a resident's actual situation "could have caused the resident to have care needs not met." She identified the MDS Coordinator as the person responsible for keeping care plans current.
The MDS Coordinator confirmed she shared that responsibility with the facility's interdisciplinary team. She told inspectors the care plans were incomplete because the facility had switched electronic health record systems in October 2025 and the migration had never been finished. "The risk in care plans not being completed and individualized," she said, "could be a failure to have needs met."
The administrator offered the same explanation. A software transition in October 2025 had left care plans in disarray, and the facility had only one MDS Coordinator to work through the backlog. She agreed, when inspectors pressed her, that the coordinator needed to focus on completing the plans. The risk, she said, was "a decreased quality of life by not having needs met."
Six months had passed since the software switch. Resident #26 had been placed on an antipsychotic during that window. He had been placed on two antidepressants. His PTSD, a condition that shapes how a person experiences daily life in a care facility, had gone unacknowledged in the document that is supposed to guide everyone who works with him.
The facility's own care plan policy, dated March 2022, states that care plans must be revised as residents' conditions change, and that a new plan must be completed within seven days of a quarterly assessment. Resident #26's quarterly assessment was completed February 23, 2026. More than two months later, inspectors found no evidence the care plan had been touched.
A care plan is not paperwork for its own sake. For a resident managing PTSD, anxiety, and suicidal ideations, it is the document that tells a night-shift aide what this person has been through, what medications he takes, what he needs when he is struggling. Without it, staff working with Resident #26 were operating without a map.
The interim DON, the MDS Coordinator, and the administrator all used nearly identical language when describing what the failure meant: needs not met, quality of life diminished. What they did not say was how long Resident #26 had been living inside that gap, taking medications for conditions his caregivers had no formal plan to address.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Arbor Terrace from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Avir at Arbor Terrace in SAN ANGELO, TX was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records as Resident #26, was mentally sharp.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.