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 care for residents in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life for one of one resident
(Resident #1) reviewed for resident rights.
The facility failed to ensure Resident #1's bed was moved, per request, as outlined in his care plan, to allow
him for more space.
This failure could place the residents at risk for depression and unmet needs.
Findings include:
Review of Resident #1 quarterly MDS assessment, dated 10/26/2023, reflected an [AGE] year-old male
who was admitted on [DATE] and had a BIMS score of 14, which indicated cognitive intactness .
Review of Resident #1's care plan, last reviewed and revised 10/19/2023, reflected the following:
Problem Start Date: 06/01/2022
Resident requests that his bed be against the wall to allow for more space in room.
Edited: 10/19/2023
Goal Target Date: 01/20/2024
Requests will be honored.
Edited: 10/19/2023
Approach Start Date: 06/01/2022
Bed against wall.
Edited: 06/01/2022
The care plan reflected Resident #1 had a diagnosis of Vascular dementia, Difficulty in walking, Other
chronic pain, Other lack of coordination, Unsteadiness on feet, Lumbago (nerve pain) with
(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:
675587
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
675587
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Adams
3011 W Adams Ave
Temple, TX 76504
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)
F 0550
sciatica left and right side, and Pneumonia.
Level of Harm - Minimal harm
or potential for actual harm
Observation of Resident #1's room on 11/13/23 at 9:50 AM revealed his side of the shared room was near
the window. His bed was positioned in the middle of his side of the room. A chair was observed between
the bed and the window accompanied by an overbed tray that held art supplies. A dresser and/or small
cabinet was positioned in front of the foot of his bed; a nebulizer was observed on top. On the left side of his
bed, a rollator walker was parked; the privacy curtain was touching the rollator walker.
Residents Affected - Few
During an interview of Resident #1 on 11/13/23 at 9:51 AM, he stated he wished he had more space in his
room. He stated when he wanted to sit in his chair in front of the window, he had to lock and park his
wheelchair on the left side of his bed and then walk to [the chair] as the wheelchair would not fit between
the foot of his bed and the dresser in front of the foot of his bed. He stated staff told him to remain on his
side of the room, but it is almost impossible because there was not enough room. He stated when he used
his breathing treatment, he could only do so at the foot of his bed. He stated he suffered from chronic pain
and COPD.
During an interview on 11/13/23 at 4:33 PM, the ADM stated she was unsure why Resident #1's bed had
not been moved to create more space in his room, according to his care plan. She stated she had not been
made aware that he wanted his bed moved. She stated when a resident requested to move their room or
any furniture, they would have requested maintenance to assist with the move. She stated she felt like
Resident #1's bed should have been moved as it was important to honor a resident's preferences.
Review of facility policy titled Resident Rights, last revised February 2021, reflected the following:
Employees shall treat all residents with kindness, respect and dignity . These rights include the resident's
right to .
g. exercise his or her rights as a resident of the facility
ee. retain and use personal possessions to the maximum extent that space and safety permit .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675587
If continuation sheet
Page 2 of 2
