Health inspection·March 21, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #1) of 5 residents records reviewed for comprehensive assessments and timing. The facility failed to ensure Resident #1 did not have a completed admission/comprehensive MDS assessment within 14 days following his admission to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's undated admission record revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. His admitting diagnoses included: surgical aftercare following surgery on the genitourinary system (surgery on the organs in the urinary system), malignant neoplasm of bladder (bladder cancer), altered mental status, diabetes (high blood sugar), chronic kidney disease (gradual loss of kidney function), muscle weakness, high blood pressure, chronic pain, heart disease, and heart failure. Review of Resident #1's MDS summary screen in his EHR on 03/21/25 revealed Resident #1's admission MDS was still in progress. His MDS was last edited on 3/18/25. In an interview on 03/21/25 at 1:19 pm, the RRM stated that the CCM was responsible for completing MDS assessments. She stated she knew about Resident #1's MDS not being completed on time because she was working on it on 3/17/25 with the CCM before the CCM left early that day due to illness. She stated that she was responsible for training the MDSC and that she had already gone over the timelines for assessments with her. Additionally, she stated that the items that still remained for Resident #1's MDS needed to be completed on-site. In an interview on 03/21/25 at 1:28 pm, the ADM stated it was his expectation that MDS assessments be completed on time and that he is aware the admission assessments must be done within 14 calendar days of admission. He stated that the CCM was recently hired into that position, and before being promoted she was a floor nurse. He stated she left early on 3/17/25 due to illness and that might be why the assessment was not completed. He stated that the RRM helps out when needed. The ADM stated he was not sure what a negative outcome to the residents would be for late MDS assessments. (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 4 Event ID: 675144 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 675144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burleson 600 Maple St Burleson, TX 76028 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)