Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Monahans during CMS and state inspections, most recent first.
Missing Parameters for Antihypertensive Medication Orders: Four residents had antihypertensive meds ordered without MAR parameters for when to administer or hold them. The affected residents included individuals with HTN and other significant diagnoses such as heart disease, CHF, CKD, and Alzheimer's disease. Staff interviews showed the DON and other staff were not aware of medication concerns, and the CR stated that antihypertensive parameters should be included on the MAR.
Incomplete person-centered care plans were identified for two residents. One resident’s care plan did not include goals or interventions for urinary incontinence, dehydration/fluid maintenance, or falls despite assessment findings, and another resident’s care plan did not document discharge preference, potential for future discharge, or assessment of a desire to return to the community. Staff interviews confirmed the missing care plan details.
Lack of Documentation Supporting Schizoaffective Disorder Diagnosis: A resident with diagnoses including schizoaffective disorder, depression, and mobility-related conditions had care plan interventions for hallucinations, delusions, and psychosis-related behaviors, but the chart lacked a comprehensive assessment supporting the schizoaffective disorder diagnosis. The CR, DON, and ADM all confirmed the evaluation could not be located, and the psychiatric physician stated he did not have a comprehensive evaluation to provide.
A resident was receiving Olanzapine for a listed diagnosis of schizoaffective disorder without any comprehensive, evidence-based diagnostic assessment documented in the medical record. The care plan and physician orders identified schizoaffective disorder as the indication for antipsychotic therapy, and a consent form and GDR were on file, but record review showed no supporting diagnostic evaluation. The DON and ADM confirmed that no comprehensive assessment existed, while the PHY stated he relied on observed symptoms such as paranoia, hallucinations, agitation, and mood issues rather than a formal assessment. This resulted in psychotropic medication being administered without documentation that met professional standards of quality or the facility’s own care plan policy.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of care needs.
Surveyors found that opened insulin vials and pens, as well as an open vial of Aplisol Tuberculin solution, were not labeled with open dates on a nurse's medication cart and in the medication room refrigerator. Interviews with nursing staff, the DON, and the Administrator confirmed that it was the responsibility of nurses to date medications when opened, and that these medications are considered good for 28 days after opening, in accordance with facility policy.
A medication aide did not perform hand hygiene before handling or administering medications to multiple residents, despite facility policy and expectations requiring handwashing or sanitizing between each medication administration. This was confirmed through observation and staff interviews, and the facility's policy mandates hand hygiene to prevent infection transmission.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
A kitchen refrigerator was found with a door that did not latch or seal properly, requiring staff to lift and close it in a specific way. The issue had persisted for over a year, with dietary staff aware of the problem but the Administrator not informed. Facility policy requiring equipment to be kept in good repair was not followed.
The facility failed to implement comprehensive person-centered care plans for residents involved in physical altercations. A resident with Wernicke-Korsakoff disorder and another with diabetes were involved in an altercation, but their care plans lacked focus areas or interventions for the incident. Similarly, a resident with cerebral palsy and another with dementia were involved in a separate altercation, and their care plans also lacked documentation of interventions. The MDS Coordinator and DON were responsible for ensuring accurate care plans but failed to address these incidents.
The facility failed to maintain essential equipment, including an industrial washing machine and a resident's wheelchair brakes, in safe operating condition. A resident with amputated legs struggled to move due to a malfunctioning wheelchair brake, which was reported but not logged for repair. The facility's maintenance policy requires documentation of broken equipment, but staff failed to follow this procedure, leading to continued use of hazardous equipment.
The facility failed to maintain a safe and sanitary environment, with broken blinds, warped tiles, and holes in walls unaddressed. The hallway 1 exit door lacked a proper seal, exposing the facility to outside elements. Maintenance issues were not documented in the work order log, indicating a lapse in reporting and repair processes. Interviews with staff revealed a lack of communication and follow-through in addressing these issues, despite the potential hazards they posed.
The facility failed to maintain a clean and homelike environment, as evidenced by a strong urine odor in a hallway and a resident with dirty bed linens. The Administrator and staff acknowledged the issues, citing housekeeping and CNA responsibilities for cleanliness. The facility's policy emphasizes a clean, comfortable environment, which was not upheld.
A facility failed to ensure an accurate MDS assessment for a resident with Wernicke-Korsakoff disorder, dementia, and anxiety disorder. The resident's care plan noted verbal behavioral symptoms, but these were not reflected in the MDS assessment. The MDS Coordinator acknowledged the error, which could lead to an inaccurate care plan and billing.
A facility failed to document the administration of Tramadol, a Schedule IV narcotic, for a resident with cognitive impairments. The medication aide did not log the 7:30 AM dose in the narcotic logbook, which was identified as a medication error. The physician, RN, and DON confirmed the necessity of logging narcotics to ensure accurate counts and prevent overmedication or drug diversion.
A facility failed to maintain effective infection control, as observed in two incidents. A medication aide touched a resident's pills with bare hands, violating hand hygiene protocols. An LVN did not change gloves between residents during blood glucose monitoring, leading to potential cross-contamination. Additionally, the facility lacked accessible PPE for Enhanced Barrier Precautions, contributing to inadequate infection control.
The facility did not maintain functioning hot water in the hand sinks of resident rooms on the 300 Hall for approximately two months due to a broken pipe. Residents used showers on other halls with hot water. The Administrator confirmed the issue and stated that approval to fix the problem was received, with no resident complaints reported. The facility shared a maintenance person with another location.
The facility failed to provide the required RN coverage for at least 8 consecutive hours a day, 7 days a week, for 16 days in Quarter 2 of 2024. This deficiency was confirmed through staffing data and staff interviews, revealing that the facility had only one full-time RN and no DON during this period. Efforts to cover shifts with agency RNs and the Regional Compliance Nurse were unsuccessful, leading to non-compliance with the facility's policy requiring RN supervision at all times.
The facility failed to maintain an effective infection prevention and control program during incontinent care for two residents. CNAs did not wash or sanitize their hands before putting on gloves and failed to change gloves after contamination, leading to potential cross-contamination. Despite training, CNAs admitted to forgetting proper procedures, highlighting a deficiency in infection control practices.
The facility failed to ensure proper pharmaceutical services by not disposing of an expired vial of Tuberculin (TB) medication found in the medication room refrigerator. The DON, new to the facility, and the Administrator both acknowledged that the oversight occurred because nursing staff did not monitor the expiration date, contrary to the facility's policy requiring safe storage and disposal of expired drugs.
A treatment cart was found unlocked and unattended, containing various medications, which violated the facility's policy requiring all drugs and biologicals to be stored securely. The DON acknowledged the oversight, and the Administrator confirmed the expectation for carts to be locked when not in use. The failure was attributed to a nurse possibly being sidetracked.
Missing Parameters for Antihypertensive Medication Orders
Penalty
Summary
Each resident's drug regimen was not kept free from unnecessary drugs because antihypertensive medication orders for 4 of 12 residents reviewed did not include parameters for when to administer or hold the medication. Resident #2, a female admitted on 01/21/2026 with diagnoses including acute respiratory failure, major depressive disorder, history of leukemia, lack of coordination, and essential hypertension, had Carvedilol ordered twice daily for hypertension, but the MAR did not include hold or administer parameters. Resident #4, a female admitted on 11/15/2024 with diagnoses including essential hypertension, anxiety disorder, lack of coordination, excoriation disorder, pain disorder with related psychological factors, and acute respiratory failure, had Diovan ordered in the morning for hypertension, but the MAR lacked parameters for use. Resident #5, a female admitted on 01/21/2026 with diagnoses including essential hypertension, atherosclerotic heart disease, cardiomegaly, and osteoarthritis, had Losartan Potassium ordered twice daily for hypertension, but the MAR lacked parameters on when to hold or administer it. Resident #10, a male admitted on 10/23/2025 with diagnoses including Alzheimer's disease, chronic kidney disease stage 4, combined systolic and diastolic heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, and heart failure, had Lotrel ordered once daily for hypertension related to heart failure, but the MAR also lacked parameters for administration or holding the medication. Staff interviews reflected that the DON and other staff were not aware of medication concerns, and the CR stated that antihypertensive medication parameters should be on the MAR.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 2 of 12 residents reviewed. For Resident #1, who had diagnoses including schizoaffective disorder, osteoporosis, osteoarthritis, lack of coordination, depression, hereditary motor and sensory neuropathy, and unsteadiness on feet, the record showed occasional urinary incontinence on the MDS and a CAA dated 3/23/2026 that identified urinary incontinence, dehydration/fluid maintenance, and falls as triggered areas requiring a new or revised care plan within 7 days. The care plan for Resident #1 was undated and lacked documentation or goals for urinary incontinence, dehydration/fluid maintenance, and falls, even though the CAA indicated these areas needed care planning. For Resident #2, who had diagnoses including acute respiratory failure, major depressive disorder, history of leukemia, and lack of coordination, the undated care plan lacked documentation of the resident’s preference and potential for future discharge. The record also did not document that a desire to return to the community was assessed. During interviews, facility staff stated they were responsible for care plans, that Resident #1 had a decline in urinary incontinence and poor fluid intake, and that Resident #2 had no plans to discharge from the facility, but these details were not reflected in the care plans reviewed.
Lack of Documentation Supporting Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that services outlined in the comprehensive care plan met professional standards of quality for one resident with a schizoaffective disorder diagnosis. Record review showed the resident was a [AGE]-year-old female admitted on 5/8/2025 with diagnoses including schizoaffective disorder, osteoporosis, osteoarthritis, lack of coordination, depression, hereditary motor and sensory neuropathy, and unsteadiness on feet. The medical diagnosis list reflected schizoaffective disorder dated 5/16/25, and the care plan included interventions for hallucinations, delusions, and behaviors related to schizophrenia/psychosis/mental illness. However, the resident's electronic health record for the period reviewed lacked documentation of a comprehensive assessment supporting the schizoaffective disorder diagnosis. During interviews, the CR C stated the psychiatry physician had been told three times that the facility needed a comprehensive evaluation to diagnose a resident with schizoaffective disorder, and that the physician had said to discontinue and delete the diagnosis because he did not have a comprehensive evaluation. The DON stated she could not locate a comprehensive evaluation for the diagnosis and that the psychiatric physician said not to discontinue it because the resident had a history of the diagnosis, but he did not have a comprehensive evaluation to provide. The ADM stated she was not aware the file lacked a comprehensive evaluation supporting the diagnosis.
Lack of Documented Evidence-Based Diagnosis for Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided, specifically psychotropic medication management, met professional standards of quality for one resident. The resident’s face sheet and medical diagnoses listed schizoaffective disorder (F25.9), and the care plan included administration of psychotropic medications, including Olanzapine, for this diagnosis. Physician orders and a signed consent for antipsychotic treatment documented that Olanzapine 2.5 mg PO BID was prescribed and administered for schizoaffective disorder, and a gradual dose reduction (GDR) was noted. However, review of the resident’s electronic health record revealed no documentation of a comprehensive assessment or diagnostic workup supporting the schizoaffective disorder diagnosis. Staff interviews confirmed the absence of required diagnostic documentation. The DON stated that the facility did not have a comprehensive assessment diagnosing the resident with schizoaffective disorder, and the ADM similarly acknowledged that there was no comprehensive assessment in the record. Despite this, the resident continued to receive antipsychotic medication for schizoaffective disorder as a listed diagnosis. The facility’s own policy on comprehensive, person-centered care plans required that care plans reflect currently recognized standards of practice, but the documentation did not demonstrate that evidence-based criteria had been used to establish the psychiatric diagnosis. Observations and interviews described the resident’s behavior and functioning over time, including initial isolation, limited participation in activities, and later increased activity and reduced aggression, as reported by nursing staff and leadership. The PHY reported that the resident had sleep and depression issues, paranoid behaviors, hallucinations, and agitation for several weeks and stated that he based the schizoaffective disorder diagnosis on these symptoms and his knowledge of the resident. The PHY acknowledged he did not use a comprehensive assessment and that supporting documentation for the diagnosis was not present in the facility’s record at the time of review. This lack of documented, evidence-based diagnostic assessment in the medical record, despite ongoing antipsychotic treatment for schizoaffective disorder, constituted the cited failure to meet professional standards of quality and to align the care plan with recognized standards of practice.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey and was based on a review of the resident's records, which did not contain a comprehensive or measurable care plan as required.
Failure to Label Opened Medications with Open Dates
Penalty
Summary
Surveyors observed that the facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles. Specifically, on two separate occasions, opened insulin vials and pens (Humalog and Novolog) were found on a nurse's medication cart without open dates labeled. Additionally, an open vial of Aplisol Tuberculin solution was found in the medication room refrigerator without an open date. These medications require labeling with the date they are opened to ensure proper tracking and timely disposal. Interviews with nursing staff, the DON, and the Administrator confirmed that it was the responsibility of nurses to date medications when opened, and that both insulin and tuberculosis solutions are considered good for 28 days after opening. The facility's own policy also required multi-dose vials to be dated and discarded within 28 days unless otherwise specified. The lack of open dates on these medications meant staff could not determine when the medications should be discarded, as acknowledged by the staff during interviews.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Medication Aide C failed to perform required hand hygiene practices while administering medications to multiple residents. Observations showed that after exiting a resident's room, Medication Aide C proceeded to pour and administer medications to additional residents without washing or sanitizing her hands. This pattern continued throughout the medication pass, with no hand hygiene performed before handling medications or between administering medications to different residents. During interviews, Medication Aide C acknowledged forgetting to perform hand hygiene and confirmed awareness of the facility's policy requiring hand hygiene prior to handling and administering medications. Further observations confirmed that Medication Aide C did not wash or sanitize her hands before preparing or administering medications to several residents in succession. The DON and Administrator both stated that facility policy and expectations require nursing staff to perform hand hygiene before handling medications and between resident medication administrations. Review of the facility's hand hygiene policy, revised in October 2023, indicated that all personnel must follow hand hygiene procedures to prevent the spread of infection, specifically before preparing or handling medications and before applying non-sterile gloves.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Kitchen Refrigerator in Safe Operating Condition
Penalty
Summary
The facility failed to maintain a kitchen refrigerator in safe operating condition, as observed during a survey. One of three refrigerators in the kitchen had a door that did not latch or seal properly, remaining slightly open unless lifted and closed simultaneously. Dietary staff were aware of the issue and had developed a method to close the door, but the problem had persisted for over a year. Staff interviews revealed that the refrigerator door had been broken for more than a year, and there was uncertainty about whether the issue had been reported to the Administrator. The Administrator confirmed that she had not been informed of the broken door prior to the survey. Facility policy requires all equipment, including seals and hinges, to be maintained in good repair, but this was not followed in this instance.
Failure to Implement Comprehensive Care Plans for Resident Altercations
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents involved in physical altercations. Resident #3, a male with a history of Wernicke-Korsakoff disorder, dementia, and anxiety disorder, was involved in a physical altercation with Resident #4. Despite having a care plan addressing verbal behavioral symptoms, there was no focus area or interventions documented for the physical incident. The Director of Nursing (DON) acknowledged the absence of a care plan for the physical behavior, which could lead to staff not knowing how to intervene. Resident #4, a male with diabetes mellitus, chronic pain, and major depressive disorder, was also involved in the altercation with Resident #3. His care plan lacked any focus area or interventions for the incident. The DON confirmed the absence of documented interventions for Resident #4's involvement in the altercation. Similarly, Resident #5, a female with cerebral palsy and intellectual disabilities, was involved in a physical altercation with Resident #6 over a phone. Her care plan did not include any focus area or interventions for this incident. Resident #6, a female with dementia, anxiety, and depression, was also involved in the altercation with Resident #5. Her care plan lacked documentation of focus areas or interventions for the incident. The MDS Coordinator and the DON were responsible for ensuring the accuracy of care plans, but they failed to address the specific incidents involving these residents. The facility's Comprehensive Assessments Policy emphasizes the importance of developing person-centered care plans based on comprehensive assessments, but this was not adhered to in these cases.
Failure to Maintain Safe Equipment Conditions
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically concerning an industrial washing machine and a resident's wheelchair brakes. The resident, who had both legs amputated, was observed struggling to move his wheelchair due to a malfunctioning right brake. Despite reporting the issue to a registered nurse, the problem was not logged in the maintenance logbook, and the necessary repairs were not initiated. The Director of Nursing (DON) and the Maintenance Director were unaware of the issue until it was brought to their attention during the survey. The facility's maintenance policy requires staff to document broken equipment in a maintenance logbook to ensure timely repairs. However, interviews revealed that staff failed to follow this procedure, leading to the resident's continued use of a potentially hazardous wheelchair. The Maintenance Director had previously provided verbal instructions on reporting broken items, but the staff did not consistently adhere to these guidelines. The Administrator acknowledged that broken equipment should be removed from use until repaired, but this protocol was not followed in this instance.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed broken blinds in two rooms, warped floor tiles, and holes in the walls in hallway 3 and the hall leading to the back smoking patio/laundry room. Additionally, the exit door in hallway 1 was missing a sweep, which failed to create a seal, exposing the facility to outside elements. These issues were not documented in the maintenance work order log, indicating a lapse in the facility's maintenance reporting and repair processes. Interviews with the Administrator, Maintenance Director, and Director of Nursing (DON) highlighted a lack of communication and follow-through in reporting and addressing maintenance issues. The Administrator acknowledged the expectation for staff to report broken items, but the Maintenance Director noted that several issues, including the missing door sweep and broken walls, were not reported to him. The DON confirmed that some issues, like the broken blinds, were discussed in meetings but not logged in the maintenance work order book. The facility's maintenance policies require that work orders be completed to prioritize maintenance services, but the review of the maintenance log revealed no documentation of the reported issues. The Maintenance Director and DON both recognized the potential hazards posed by the unaddressed maintenance issues, such as trip and fall risks and exposure to outside elements, but these concerns were not adequately documented or addressed in a timely manner.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in one of its hallways and for one resident. During an observation, the hallway was found to have a strong odor of urine, which was confirmed by the Administrator, who acknowledged the inappropriate nature of the smell and indicated that housekeeping was responsible for addressing such issues. This failure to maintain cleanliness in the hallway could contribute to an uncomfortable and unsanitary environment for residents. Additionally, a resident was found to have dirty bed linens with a large brown unknown substance on them. Interviews with the Director of Nursing (DON) and Certified Nursing Assistants (CNAs) revealed that it was the responsibility of the CNAs to ensure that bed linens were clean and changed regularly. The DON and CNAs acknowledged that having dirty or stained sheets was not acceptable and was considered a dignity issue for the residents. The facility's Homelike Environment Policy emphasized the importance of providing a clean and comfortable environment, which was not upheld in this instance.
Inaccurate MDS Assessment for Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the resident's behaviors. The resident in question, a male with a history of Wernicke-Korsakoff disorder, dementia, and anxiety disorder, was admitted to the facility and later re-admitted. Despite having a care plan that identified verbal behavioral symptoms such as threatening, screaming, and cursing at others, the resident's MDS assessment did not reflect these behaviors. This discrepancy was identified during a review of the resident's records and an interview with the MDS Coordinator. The MDS Coordinator acknowledged that the MDS assessment for January 2025 was incorrect as it failed to document the resident's behaviors in the Behavioral Section (E) of the MDS. The coordinator admitted that this inaccuracy could lead to an incorrect care plan and inaccurate billing. The responsibility for ensuring the accuracy of the MDS assessment was stated to be that of the MDS Coordinator. This oversight in accurately documenting the resident's behaviors could potentially place residents at risk of not receiving adequate care.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the accurate documentation of narcotic medication administration. A medication aide (MA) did not record the administration of Tramadol, a Schedule IV narcotic, in the narcotic logbook after giving it to a resident at 7:30 AM. This omission was identified during an observation and interview, where the MA acknowledged forgetting to log the medication and noted it as a medication error. The physician and RN confirmed that narcotic medications must be documented in the logbook at the time of administration to ensure accurate medication counts and prevent potential overmedication or drug diversion. The resident involved had a history of Wernicke-Korsakoff disorder, dementia, and anxiety disorder, and was prescribed Tramadol four times daily. The facility's policy requires medications to be administered safely and documented by licensed personnel, with errors reported and reviewed by the QAPI committee. The Director of Nursing (DON) emphasized the importance of logging narcotics to maintain accurate medication records and prevent discrepancies that could lead to overmedication or theft. The failure to document the administration of Tramadol in the narcotic logbook represents a breach in the facility's medication management procedures.
Infection Control Deficiencies in Medication Administration and Cross-Contamination
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. One significant issue involved a medication aide (MA A) who administered medication to a resident without adhering to proper hand hygiene protocols. MA A was observed touching a resident's pills with her bare hands, which is against the facility's policy that requires medications to be handled without direct skin contact to prevent contamination. This lapse in protocol was acknowledged by the Director of Nursing (DON), who confirmed that the facility's policy mandates that medications should be handled using a cup or lid to avoid contamination. Another deficiency was noted with an LVN who failed to prevent cross-contamination between two residents during blood glucose monitoring. The LVN did not change gloves between residents and used the same contaminated gloves to handle various items, including the medication cart and glucometer strips. This practice led to potential cross-contamination, as the LVN did not clean the glucometer strips container after it was placed on a resident's bed. The LVN admitted to not following proper glove-changing protocols and acknowledged the oversight when it was pointed out by the surveyor. Additionally, the facility did not provide adequate personal protective equipment (PPE) for staff to follow Enhanced Barrier Precautions (EBP) for residents with indwelling devices. The LVN was aware of the need to wear a gown and gloves for residents under EBP but did not do so because gowns were not readily available outside the resident's room. The DON admitted that the current process of storing gowns at the nurse's station was ineffective, as it required staff to travel across the building to access them. This lack of accessible PPE contributed to the failure in maintaining proper infection control measures.
Failure to Maintain Hot Water in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 300 Hall by not maintaining functioning hot water in the hand sinks of residents' rooms. Observations over a three-day period revealed that the hand sinks in these rooms had no hot water, as the hot water did not turn on at all. An interview with the Administrator confirmed that Hall 300 had been without hot water for approximately two months due to a broken pipe. During this time, residents used showers on other halls that had hot water. The Administrator mentioned that several quotes had been obtained, and approval from corporate to fix the hot water was received on the morning of the interview. The Administrator also noted that no residents had complained about the lack of hot water and believed there was no negative outcome since alternative showering arrangements were made. The facility did not have a dedicated maintenance staff and shared a maintenance person with another facility.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, for 16 days during Quarter 2 of 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report, which highlighted the absence of licensed nursing coverage on specific dates in January and February 2024. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Regional Compliance Nurse, confirmed the lack of RN coverage on these days. The ADON acknowledged that the facility had only one full-time RN and no Director of Nursing (DON) during this period, while the Regional Compliance Nurse, who was covering for the DON, did not work on the days in question. The facility's administrator explained that the staffing issues arose following a change in ownership, which led to the loss of staff, including the DON. Despite efforts to provide coverage with agency RNs and the Regional Compliance Nurse, the facility was unable to meet the required RN coverage. The facility's policy, revised in August 2006, mandates that the nursing services department be under the direct supervision of an RN at all times, with a DON employed to oversee operations during the day shift. However, this policy was not adhered to during the specified period, resulting in the deficiency.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs A, B, and C during incontinent care for two residents. For Resident #4, CNAs A and B did not wash or sanitize their hands before putting on gloves and failed to change their gloves after they became contaminated during the care process. This included handling the resident's gown, call light, and bed remote with contaminated gloves, which could lead to cross-contamination and the spread of infection. Both CNAs admitted to forgetting to perform proper hand hygiene and glove changes due to nervousness, despite having received training on these procedures. Similarly, CNA C did not change gloves after they became contaminated while providing incontinent care for Resident #17. CNA C continued to handle clean items, such as a new brief and the resident's clothing, without changing gloves, which is against the facility's infection control policy. During an interview, CNA C acknowledged the oversight and recognized the potential infection control issue after being informed by the surveyor. The facility's policies on hand hygiene and infection prevention emphasize the importance of washing hands and changing gloves to prevent the spread of infections. However, the actions of the CNAs during the observed care episodes did not align with these policies, resulting in a deficiency in the facility's infection control practices. The failure to adhere to established procedures for hand hygiene and glove use poses a risk of cross-contamination and infection transmission among residents.
Expired TB Medication Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper storage and timely disposal of expired medications in the medication room. During an inspection, a vial of Tuberculin (TB) medication was found in the refrigerator with an open date of 04/29/24, despite the box instructions indicating it should be discarded after 30 days. The Certified Medication Aide (CMA) present during the inspection was unaware of the expired formula, as she did not administer TB tests. The Director of Nursing (DON), who had just started working at the facility, acknowledged that the TB formula should have been dated when opened and discarded or returned to the pharmacy when expired. The DON noted that the failure occurred because the nurses responsible for using the TB formula did not pay attention to the expiration date. The facility's policy, dated April 2007, mandates that all drugs and biologicals be stored safely and that expired drugs be returned to the pharmacy or destroyed. The Administrator confirmed that it was the nursing staff's responsibility to monitor and dispose of expired medications, and the oversight was due to the nurses not noticing the expired TB formula.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. During an observation, a treatment cart was found unlocked and unattended, containing various medications such as antifungal creams, triple antibiotic ointments, scissors, nail clippers, and medicated bandages. This oversight was noted during a survey, and the Director of Nursing (DON) acknowledged that the cart should have been locked when unattended. The DON was unsure who left the cart open but confirmed that it was the responsibility of nurses or medication aides to lock the cart when not in use. The facility's policy on medication storage, dated April 2007 and January 2024, mandates that all drugs and biologicals be stored securely and that medication carts should not be left unattended if open. The Administrator confirmed that the expectation was for medication or treatment carts to be locked when not in use. The failure to lock the cart was attributed to a nurse possibly being sidetracked and leaving the cart unlocked. Both the DON and the Administrator stated that they conducted rounds to ensure carts were locked when unattended.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monahans
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Crane | 34.3 mi | ★★★★★ | 0 | 0 |
| Sienna Nursing And Rehabilitation | 34.5 mi | ★★★★★ | 24 | 0 |
| Focused Care At Odessa | 34.9 mi | ★★★★★ | 12 | 0 |
| Buena Vida Nursing & Rehab Odessa | 38.8 mi | ★★★★★ | 4 | 0 |
| Avir At Pecos | 39.1 mi | ★★★★★ | 32 | 0 |
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