Health inspection·August 11, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure assessments accurately reflected the resident's status for 1of 2 residents (Resident #' 21) reviewed for PASSR Evaluation. Residents Affected - Few 1. Resident #21's admission MDS dated [DATE] inaccurrately documented the resident did not have serious mental illness despite having diagnoses including Schizophrenia. This failure could place residents at risk of inadequate care and services based on inaccurate assessment and place residents at risk of inaccurate information being transmitted to CMS which uses the data to shape future regulations and improve the quality of life and care for residents who live in nursing facilities. The findings included: Record review of Resident #21's face sheet, not dated, revealed a [AGE] year-old male with a re-admission date of 01/11/2022 and the latest return date of 07/03/2022. The resident had diagnoses which included: Schizophrenia, Major Depressive Disorder, Psychosis, and unspecified Dementia without behavior disturbance. Record review of Resident #21'correction MDS dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment Record reviews of Resident #21 's EMR and the long-term care portal documentation on 08/11/22, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), and was dated 1/11/22 and, indicated yes for mental illness. His PE section for mental Illness was documented as completed on 01/28/22. Section C, (the section of the PE pertaining to Mental Illness) documented the resident had the following Mental Illness Diagnoses: mood Disorder bipolar, major depression or other mood disorder, psychotic disorder, and schizoaffective disorder (all of these conditions are classified as mental illness diagnoses by the Diagnostical and Statistical Manual of Mental Disorders 5th Edition - DSM-5). Resident #21's admission MDS dated [DATE] Section A 1500 indicated no, the resident had not been evaluated by level 2 PASRR and determined to have a serious mental illness. A 1510 Level 2 PASRR conditions did not indicate that the had a serious mental illness or other related condition. During an interview with MDS Regional Consultant on 08/11 /22 at 10:35 AM she stated Resident 21's admission MDS dated [DATE], section A1500 and A1510 were marked no for Mental illness, and this would be an inaccuracy. MDS nurse stated she was unaware this was an MDS inaccuracy and confirmed the resident did have diagnoses of Schizophrenia, Mood disorder. (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 6 Event ID: 675708 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 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr Weatherford, TX 76086 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)