Health inspection·May 22, 2024

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 interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1 had physician orders for crushed medications on the electronic medication administration record (EMAR ). This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, and Health Record information revealed an admission date of 5/17/24 with diagnosis to include Alzheimer's disease. Record review of Resident #1's initial MDS dated [DATE] revealed a BIMS score of 00/15 which indicated unable to perform due to cognitive status. Record review of Resident #1's care plan dated 5/17/24 revealed needs anticipated by the staff. Required total assistance with activities of daily living. Record review of Resident #1's physician orders provided by hospice dated 5/17/2024, revealed order for Medication pass: crush medications. Record review of Resident #1's EMAR dated 5/17/2024- 5/18/2024 showed no order for medications to be crushed . During an interview on 5/21/2024 at FM of Resident #1 stated he required his medications to be crushed as he had difficulty in swallowing pills. She further revealed she had informed a staff member at the facility. She could not remember the name of the staff member. During an interview on 5/21/2024 at 2:45 pm LVN B stated she assisted LVN A with admission paperwork for Resident #1 and LVN C placed Resident #1's physician orders in his EMAR. She further revealed Hospice Nurse E informed her that Resident #1 required his medications to be crushed. She stated there should have been an order placed in the EMAR so that the staff would know to crush Resident #1's medications. She further revealed it was the practice of the facility to place a separate order in (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: 675452 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 675452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Converse 7700 Mesquite Pass Converse, TX 78109 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)