Inspection·December 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 3 (Resident #2) residents reviewed for urinary catheter care. The facility failed to place Resident #2's urinary catheter in a privacy bag. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life. Findings include: Record review of the MDS dated [DATE] revealed Resident #2 was a [AGE] year old female admitted [DATE], with a BIMS score of 12 indicating mild cognitive impairment. Medical Diagnoses include nausea with vomiting, muscle weakness, muscle wasting and atrophy, obesity, pressure ulcer of sacral region and cellulitis. Record review of Residents #2 Care Plan dated 10/16/23, Category Urinary Incontinence, stated 'store collection bag inside a protective dignity pouch'. Observation and interview on 12/7/23 at 9:51 a.m., revealed Resident #2 lying in bed watching tv, the urinary catheter bag was placed on the right side down by the foot of the bed, no privacy cover and urinary catheter bag can be seen from hallway. Resident #2 stated she did not know the catheter bag did not have a privacy cover and stated she would like for it to be covered. In an interview with the DON on 12/7/23 at 10:18 a.m., the DON stated she expected that all catheter collection bags on beds and (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: 675259 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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)