Avir At New Braunfels

Review of the facility's policy PASARR, dated 7/29/25 read in relevant part The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 4.

Care Planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs.

Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at New Braunfels

821 US Hwy 81 W New Braunfels, TX 78130

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, to store all drugs and biologicals under proper temperature controls in 1 of 1 central supply storage room reviewed for medication storage.

The facility failed to store their over-the-counter medications (8 bottles of Acetaminophen 325 mg.) in the central supply storage room maintained within 68 to 77 degrees Fahrenheit per medication recommendations.

This deficient practice could place residents at risk of the medications not being as effective as they were designed to work.

The findings were:Observation and interview on 11/18/25 at 2:01 PM with CNA A in the central supply storage room revealed she was assigned as the charge person for ordering and storing medications in the central supply storage room as of 10/1/25.

She stated when she started organizing the storage room, she noted it was hot in the storage room and there was no ventilation. CNA A stated they stored nursing supplies including over the counter medications, enteral feedings and med pass. A thermometer was observed hanging on a top shelf. It was not registering a reading.

There was a red line all the way across to the right side into the red area which read danger. It felt very stuffy and hot in the storage room.

Observation and interview on 11/18/25 at 3:10 PM with the MS and CNA A in the central supply room revealed the temperature was hot.

The MS stated he talked to the ADM about it being too hot in the central supply room. the MS used a laser thermometer to take a reading, and it read 84 degrees. He stated he did not know what the regulation was but would find out.

The MS stated he talked to the ADM about adding an AC unit in the back service hall where the central supply storage and laundry were located. He stated the AC unit that should be cooling the service hall did not have a thermostat attached to provide airflow in the service hall. CNA A stated she spoke with a corporate staff person about the temperature in the central supply room.

She stated the corporate staff brought the ADM into the storage room while she was in the room and told him he had to get it fixed ASAP because it was too hot.

Interview on 11/18/25 at 3:50 PM with the ADM revealed he talked with their previous corporate staff about the temperature in the central supply room.

The ADM stated they had other issues they were also addressing at the time and then the new company bought them out about 2 months ago. He stated he had not talked to the current corporate staff about it yet.

The ADM stated he knew there was a regulation for maintaining the storage area at a safe range but was not sure about the specifics. He stated if the medications were not stored within acceptable parameters, it could compromise the efficacy of the medications, and the medications would not work effectively on the residents.

The ADM was asked for a policy on storage of over-the-counter medications on. It was not provided by the end of the investigation period on 11/24/25.

Observation and interview in the central supply room on 11/19/25 at 2:49 PM with the DON revealed she stated it was really hot in the storage room.

She stated she talked with the ADM about it but they had not had a discussion about a plan to cool the storage room.

She stated she checked the temperature requirements for the over-the-counter medications and found the bottles of Acetaminophen 325 mg. read they should be stored at temperature within 68 to 77 degrees.

Fahrenheit.

The DON stated storing the medication exceeding the recommended storage temperature could affect the efficacy of the medication and not effectively help the residents.

Observation revealed there were 8 bottles of Acetaminophen 325 mg. on a shelf.

The label on the box read Store at 20-25 degree C (68-77 degrees F).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at New Braunfels

821 US Hwy 81 W New Braunfels, TX 78130

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1.

The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2.

Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards.

Review of the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1.

Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the resident's right to: a. a dignified existence.

Facility ID: