Health inspection·February 20, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Resident #1) of 6 residents reviewed for privacy. Residents Affected - Few Resident #1's medical information was shared with a surgeon via a nurse's personal email account. This failure could affect the residents residing in the facility by placing them at risk of losing their right to privacy and confidentiality. Finding included: Record review of Resident #1's Face Sheet dated 02/19/2025 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to cellulites of left lower limb, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene(blockage of blood vessels affecting toes and feet), acquired absence of left left leg below the knee, contracture, right hip acquired absence of right leg below knee. Record review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 15 out of 15 indicating Resident #1's cognition was intact. Record review of Resident #1's progress notes dated 02/10/2025 revealed LVN A documented the following: Staff from surgery center returned call regarding decline in wound. Pictures emailed. Staff states they will talk to the provider with it tomorrow, and she will call back with any new orders. Progress notes dated 02/14/2025 revealed LVN A documented the following: Received return email from surgeon's office on this nurse's day off. Nurse states that physician would like resident sent to their ER for possible surgical debridement. In an interview on 02/19/2025 at 12:20 PM, The ADON said that she did not know that LVN A sent the pictures of the resident via per personal email on 02/11/2025 until she was reading documentation in the progress notes . The ADON said LVN A should have told Administration personnel about the request from the surgeon because it was not her responsibility to email the pictures it was the Administration personnel's responsibility. The ADON stated staff do not have email accounts through the facility only Administration personnel have email accounts. (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 5 Event ID: 675055 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 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)