Inspection·August 16, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and/or accurate for 1 of 1 resident (Resident #1) reviewed for clinical records. The facility did not maintain or complete progress notes or round sheets or Resident #1. This failure could place residents at risk for inaccurate documentation by staff. The findings were: Record review of clinical records for Resident #1 revealed a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions), generalized anxiety disorder (state of anxiousness), and insomnia (difficulty falling asleep). Record review of Resident #1's progress notes from an elopement observation made by the LVN A, dated 08/12/2023, at 8:30 PM, revealed the following: CNA's will do hourly checks on resident through the night to ensure safety. Record review of Resident #1's nursing notes, progress notes and observations, dated 08/12/2023 and 08/13/2023, revealed hourly rounds were not documented. Record review of Resident #1's Care plan, dated 08/01/2023, revealed the following: Elopement: I wander due to my diagnosis of age-related cognitive decline. I wear a roam alert bracelet. Goal: I will not elope from the center in the next 90 days. Record review of a Quarterly MDS, dated [DATE], revealed the following: Section C entitled BIMS revealed a score of 03, which indicated the resident was severely impaired. Section E entitled Behavior Assessment revealed: Wandering behavior not exhibited with the last 7 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455555 Printed: 05/15/2026 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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)