Avir At Lubbock

F 0600

housekeepers, and office staff as needed.

Level of Harm - Immediate jeopardy to resident health or safety

During an interview on 09/05/25 the admission Coordinator was in-serviced to ensure referrals for new admissions are reviewed prior to admission. If a resident is identified with a history of sexual or physical aggression, this will be care planned to include interventions for staff to follow.

Residents Affected - Few

During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all resident

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

aggression, this will be care planned to include interventions for staff to follow. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the memory unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included

the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant,

the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and ADON would do the random audits for 1:1 supervision but on the weekend, he had an RN supervisor. He stated he gave staff

the opportunity to ask questions if they needed to. He stated Admissions was trained in reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. During an interview on 9/05/25 at 2:07 PM the DON stated they di

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

specifically the revision for Resident #8 regarding behavior should have happened at the time of the incident by the DON or designee. He stated he did not have a reason why Resident #8's care plan was not completed after the incident of aggression on 08/05/25 and 08/29/25. During an interview on 9/05/25 at 3:54 PM the ADON stated she was familiar with the facility policy regarding care plan and revisions. She stated the initial care plan was completed by the DON and then from there the IDT updated them in morning meetings and then the MDS Coordinator will update the resident care plan accordingly. She stated

she was unaware that Resident #8's care plan was not updated after he had an altercation with other residents on 08/05/25 and 08/29/25. The ADON stated the potential negative outcome for not revising a resident's care plan was things could be missed and then they (the facility) could have a bigger issue. She sated care plan revisions she had some training, bits and pieces here and there. She stated she had [NAME] had a formal class before. The ADON stated she expected that when care plan revision were needed, she expected that they all meet as a team in the morning meetings so that they all ensure that the residents were getting the proper care that they needed. The ADON stated she did not have a reason why

the care plan was not revised, and that the IDT team would be responsible for care plans revisions as it was

a group effort. Record review of the facility's policy, Comprehensive Care Plans, dated July 2025, revealed:PolicyIt is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives in time frames to meet a residence medical, nursing, and mental and psychosocial needs in all services that are identified in the residence, comprehensive assessment and the professional standards of quality. The comprehensive care plan will describe, at minimum, the following: The services that are to be furnished to attain or maintain the residence, high practical, physical, mental and psychosocial well-being. Resident specific interventions that reflect the residence needs and preferences in align with the residence, culture identity, as indicated. The comprehensive care plan will be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment. The comprehensive care plan will include measurable objectives and timeframe to meet the residence needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the residence progress. Alternative interventions will be documented as needed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0689

Exploitation, Levels of Observation, and Resident to Resident Altercat

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

regulations.ProceduresAt each shift change or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and his documented. Any discrepancy and controlled substance counts is reported to the Director of Nursing immediately the director or designated investigates and makes every reasonable effort to reconcile all reported discrepancies. The Director of Nursing documents in reconcilable discrepancies and a report to

the administrator. If I made a discrepancy your pattern of discrepancies occur, or if there is parent, criminal activity, the Director of Nursing notifies the administrator and consultant pharmacist immediately. The administrator, consultant pharmacist in or directive nursing determine whether other actions are needed.Controlled substance inventory is regularly reconciled to the medication administration, record, and documentation. Current controlled substance accountability records are kept in the MAR, or designated book.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurses had not had any specific formal training from the facility. The ADON stated she did not think anything of the 14 day stop date as she thought since it was prescribed and apart of hospice it would be considered apart of palliative care. The ADON stated she expected her nurses to pay attention to the stop date when

the medication was ordered. She stated the nurse receiving the order should ensure that the PRN medication had the 14 day stop date and should be reordered timely. The ADON stated there was no reason why Resident #4 and #6 PRN Lorazepam did not have a 14 day stop date. The ADON stated she assumed it was hospice that ensured there was a 14 day stop date but that it should be whichever nurse enters the order in the resident's EMR. The ADON stated she would follow up with the HHSC investigator

on the purpose of the Lorazepam for Resident #6. The ADON stated Lorazepam was not typically used for pain. The ADON stated she did not have a reason why Resident #4's physician order was not updated to reflect the 90 day stop date that was indicated on the pharmacy recommendation from 2024, but that she expected the resident's physician order to be updated and reflect the recommendation from the Pharmacy Consultant and the assigned doctor. The ADON stated she would have expected the hospice provider to update the resident's EMR. She stated she is unsure if the hospice provider had access to the facility's EMR system. During an interview on 9/10/25 at 11:07 AM the Pharmacy Consultant stated he was unsure if he had already identified the lack of a 14 day stop date for Resident #4 and Resident #6. He stated he would have look at his notes and he was not where he could access the notes. He stated any documentation needed would have to be requested from the facility. He stated he does regimen reviews and if he identified there was a PRN antianxiety or antipsychotic, he generally would let the facility and doctor know through written notification. The Pharmacy Consultant stated the potential negative outcome for not having a 14 day stop date was the resident could receive the medication longer than he or she needed. Record review of the facility's policy, Use of Psychotropic Medications, dated July 2025, revealed:PolicyIt is the intent of this policy to ensure that residents only receive psychotropic medication‘s when other non-pharmacological interventions are clinically contraindicated. Additionally, this medication should only be used to treat the residence, Medical Center, and not used for discipline or staff convenience, which would deem it as a chemical restraint.Psychotropic medication's use on a PRN basis must have a diagnose specific condition and indication for the PRN use document in the residence medical record in a subjected to the limitations as noted: PRN orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner, believes

it is appropriate to extend the order beyond the 14 days. The medical records should include documentation from the physician or prescriber for the rationale for the extended time. And indicate a specific duration.

PRN orders for antipsychotic medication's only, shall be limited to 14 days with no exception. If the attending physician or prescribing practitioner, believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Lubbock

4710 Slide Rd Lubbock, TX 79414

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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

were supposed to conduct the audits either once a week or once every two weeks. The ADON stated the Pharmacy Consultant also will conduct medication cart audits. The ADON stated she had not noticed the liquid Lorazepam in medication carts nor Resident #5's Lorazepam not being labeled properly. The ADON stated she had been trained that to adhere to medication/pharmacy labels. She stated it was a nursing standard. The ADON stated she expected for her nurses and medication aides to pay attention to the medications in their medication cart. She stated if medications were to be in the refrigerator she expected

the nurses and medication aides to place them in the refrigerator. The ADON stated there was no reason why the liquid Lorazepam was not in the refrigerator. The ADON stated the reason why Resident #5's Lorazepam was not labeled correctly was because hospice brought it to the facility in that condition. The ADON stated all nursing staff and medication aides were responsible for ensuring that the medication labels were adhered to and stored properly. The ADON stated the filled date listed on the resident's medication was the date the medication was brought to the facility. During an interview on 9/09/25 at 1:53 PM LVN L stated she was familiar with the facility's policy, Medication Storage and labeling, and the purpose of following the policy was to ensure that medications were stored properly. She stated medication should be at the proper temperature before administration. LVN L stated the potential negative outcome for not properly storing medications was the Lorazepam could evaporate or not have as potency and effectiveness. LVN L stated then the medication would not work for the resident. LVN L stated she had been trained if the medication was left out then the medication would need to be placed in the refrigerator. LVN L stated the system to monitor medication storage was to place the Lorazepam in the refrigerator once it was received or they identify in the medication carts. LVN L stated she had been trained to adhere to pharmacy labels and the nurses were responsible for ensuring that all medications were stored properly. LVN L stated

she did not have a reason why Resident #4 and Resident #6 Lorazepam was on the medication cart and not in the refrigerator as instructed on the medication label. LVN L stated the filled date on the medication label was not normally the date the facility received the medication because the facility would not receive

the medication until the following day at 3:00 AM or 4:00 AM.During an interview on 9/10/25 at 11:07 AM

the Pharmacy Consultant stated he was unaware that the facility had liquid Lorazepam that was not being stored in the refrigerator. He stated he was unsure what the potential negative outcome was for the resident if the liquid Lorazepam was not stored in the refrigerator as the pharmacy label instructed. He stated it may depend on the manufacturer and that some manufacturers require for the medication to be sat out prior to administration of the dose. The Pharmacy Consultant did not provide a potential negative outcome for not having a legible label but stated that if the label was not legible then the facility staff needed to call the pharmacy and get a replacement. Record review of the facility's policy, Medication Storage in the facility, dated January 2018, revealed:Policy: medication is included in the drug enforcement administration classification is controlled. Substances are subject to special handling, storage, disposal and recordkeeping

in the facility in accordance with federal, state and other applicable laws and regulations.ProceduresControlled substances that require refrigeration are stored within a lock box within

the refrigerator. This box must be attached to the inside of the refrigerator. A controlled substance accountability record is prepared by the pharmacy/facility for all schedule II, III, IV, and V medications, including those in emergency supply. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance or use of a controlled substance: name of the resident, name, strength, and dosage form of the medication, date received, quantity received, and name of the person receiving the medication.

Event ID:

Facility ID:

If continuation sheet