Avir At Arbor Terrace
Avir at Arbor Terrace in SAN ANGELO, TX — inspection on April 30, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 4/30/2026 at 5:00PM with the Administrator she stated it was the MDS Coordinator's responsibility to update and follow through with PASRR.
She stated the risk in not doing so could lead to decrease in quality of life and not receiving services that could be beneficial to the resident.
During a record review of facility's policy dated 11/2023 titled PASRR revealed:6.
Follow the Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in residents' PASRR status.
Review of the Texas Health and Human Services Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form, revised June 2023, and accessed at PASRR Forms and Instructions | Texas Health and Human Services revealed in part, The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD).
Developmental disabilities are also referred to as related conditions.If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, or DD, a PASRR Evaluation (PE) must be completed to confirm PASRR eligibility.
The PE is designed to confirm the suspicion of MI, ID, or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning.Examples of MI diagnoses are:SchizophreniaMood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder)Paranoid DisorderSevere Anxiety DisorderSchizoaffective DisorderPost-Traumatic Stress SyndromeWhat is not considered an MI:Neurocognitive Disorders, such as Alzheimer's disease, other types of dementia, Parkinson's disease, and Huntington's. (DSM-5*), Depression, unless diagnosed as Major Depression; and Anxiety, unless diagnosed with severe anxiety disorder.*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
675932 04/30/2026
Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903
being admitted
interviews and record review the facility failed to develop a baseline care plan within 48 hours of
resident that met professional standards of quality of care for 1 of 5 residents (Resident #80) reviewed for baseline care plans.
The facility failed to develop the baseline care plan for Resident #80 within 48 hours following his admission on [DATE].This failure could place residents at risk for complications due to the potential for their immediate needs not being identified so interventions could be planned and initiated.
Findings included: A record review of Resident #80's Resident Face Sheet, dated 4/30/2026, revealed a [AGE] year old male admitted to facility on 4/27/2026 with diagnoses of Chronic Kidney disease stage 5 (most advanced stage of chronic kidney disease requiring dialysis), dependence on renal dialysis (medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed), neuromuscular dysfunction of the bladder (occurs when nerve damage interrupts signals between brain, spinal cord, and bladder muscles, causing loss of control, urinary retention or overactive bladder symptoms), and anxiety (mental health condition characterized by excessive, uncontrollable, persistent worry about daily life events).A record review on 4/30/2026 of Resident #80's electronic clinical records revealed the facility had not developed an initial baseline care plan within 48 hours of his admission.
During an interview on 4/30/2026 at 3:50PM, the Interim Director of Nursing (DON) confirmed that a baseline care plan had not been developed within the 48-hour timeframe. DON stated she started the baseline care plan today.
She said her expectation was for the baseline care plans to be completed within the first 48 hours after admission by an RN.
Interim DON stated the risk of not completing the baseline care plan was staff not knowing how to care for the resident.
During an interview on 4/30/2026 at 5:00PM with the Administrator she stated her expectation was for nursing to complete the baseline care plan upon admission.
She stated the risk in not completing the baseline care plan timely could affect the residents' quality of care by staff not knowing how to care for the resident.Baseline care plan policy requested from DON on 4/30/2026 at 3:00pm. No policy for baseline care plans was received prior to exit.
675932 04/30/2026
Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903
life threatening, or traumatic events), anxiety disorder (mental health condition characterized by
dated 02/23/2026, revealed Resident #26 had a BIMS score of 15 which indicated no cognitive
N-Medications included antipsychotic and antidepressant usage.
Record review of Resident #26's order summary dated 4/30/2026 revealed he was prescribed duloxetine (an antidepressant medication) since 12/8/2025, olanzapine (an antipsychotic medication) since 11/10/2025, and trazadone (an antidepressant medication) since 4/29/2026.
Record review of Resident #26's Care Plan, initiated 02/13/2025, revealed no evidence of antipsychotic medication use or diagnosis of PTSD.
During an interview on 4/30/2026 at 3:01 PM, the Interim DON stated her expectation was that medications and diagnoses are care planned.
The DON stated the effect on the resident for their care plans not being accurate could have caused the resident to have care needs not met.
The DON stated that the MDS Coordinator was responsible for updating the care plans based on resident needs.
The DON stated what led to this failure was that the facility was transitioning from one electronic health record program to another in October of 2025 and all the care plans have not been completed.During an interview on 4/30/2026 at 3:33 PM with the MDS Coordinator she stated she was responsible for completing care plans with the Interdisciplinary Team.
She stated some of the care plans are not complete because in October of 2025 they changed electronic health records.
She stated the risk in care plans not being completed and individualized could be a failure to have needs met.During an interview on 4/30/2026 at 5:00PM with the Administrator, she stated they have changed electronic health record programs.
The Administrator stated she only had 1 MDS Coordinator right now to enter all care plans.
The Administrator agreed that the MDS Coordinator needs to focus on completing care plans.
The Administrator stated that the risk of care plans not being completed could be a decreased quality of life by not having needs met.
Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: The comprehensive, person-centered care plan includes measurable objectives and timeframes; to meet the residents highest practicable physical, mental, and physical psychosocial well-being.2.
The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment.11.
Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.
675932 04/30/2026
Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903
Findings included:
Record review of Resident #45's admission record dated 04/30/2026 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and weakness. He was [AGE] years of age.
Record review of Resident #45's MDS quarterly assessment dated [DATE] indicated in part: BIMS =score of 11 indicating resident was moderately cognitively impaired.
Section O: Special Treatments, Procedures, and Programs = Oxygen therapy.
Observation and interview on 04/30/2026 at 2:25 PM the Resident #45's oxygen nasal cannula tubing was seen wrapped around the back of the oxygen tank with no protective cover or bagged on the back of the wheelchair. Resident #45 said the staff had taken his nasal cannula off after they moved him from his wheelchair to his bed and placed it on the oxygen tank.
Interview on 04/30/2026 at 5:12 PM the Administrator was made aware of the observations of the oxygen nasal cannula not stored in the bags.
The Administrator said that it was expected for staff to store the cannulas in the bags when they were not in use.
The Administrator said if the cannulas were not stored in the bags then that could possibly lead to the residents acquiring respiratory infections.
There was no policy provided regrading regarding oxygen administration or storage of nasal cannula tubing .
675932 04/30/2026
Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903
Findings included: Observation on 04/28/2026 at 10:56 AM in resident room A-2 there was lint built up on the exhaust fan vent located in the restroom.
Observation on 04/28/2026 at 10:58 AM in resident room A-5 there was lint built up on the exhaust fan vent located in the restroom.
Observation on 04/28/2026 at 11:02 AM in resident room B-3 there was lint built up on the exhaust fan vent located in the restroom.
Observation on 04/28/2026 at 11:08 AM in resident room C-7 there was lint built up on the exhaust fan vent located in the restroom.
Observation on 04/28/2026 at 11:12 AM in resident room D-6 there was lint built up on the exhaust fan vent located in the restroom.
Observation on 04/30/2026 at 8:30 AM in resident room F-7A and B the following issues were seen in the restroom.
There were some holes in the walls behind the toilet and sink and the baseboard was hanging off the wall.
Also, the sheetrock was deteriorating and crumbling in spaces and there were visible holes around plumbing pipes.
There was lint built up on the exhaust fan vent.
Interview on 04/30/2026 at 4:50 PM the Maintenance Director said they were in the process of cleaning the vents in the restrooms.
The Director said they did that periodically but had not done it recently.
The Director said he understood how those issues could affect the quality of life for the residents as those issues did not appear to be homelike.
Interview on 04/30/2026 at 5:24 PM the Administrator said she understood how the issues with the environment could lead to the residents feeling sad and not having a homelike environment.
The Administrator said they would work with getting those issues repaired.
Record review of the facility's Maintenance Director job description dated 08/2024 indicated in part: Supervise and coordinate activities of workers (including self) engaged in maintaining and repairing physical structures and contents of buildings and maintaining grounds.
Keeps the interior in good repair which includes drywall repair, painting, cleaning carpets and miscellaneous other duties.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.