F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and interview , the facility failed to provide privacy for 1 (Resident #1) of 8 residents observed
for incontinent care in that:
Residents Affected - Few
Resident #1's room door was left open, and the curtain was not drawn during incontinent care offering no
privacy, allowing full visual exposure of Resident #1 on 11/14/2023 at 5:08am.
This deficient practice could affect residents who require care and monitoring and place them at risk of not
receiving privacy and dignity during personal care and services to meet their needs.
The findings included:
Record review of Resident #1's face sheet dated 11/14/2023 documented a [AGE] year-old female admitted
to the facility on [DATE] with a diagnosis of MUSCLE WASTING AND ATROPHY( wasting or thinning of
muscle mass), NOT ELSEWHERE CLASSIFIED, OTHER SITE, HEMIPLEGIA(paralysis of one side of the
body), UNSPECIFIED AFFECTING LEFT NONDOMINANT SIDE.
Record review of Resident #1's MDS dated [DATE] documented: Resident #1 requires Extensive assistance
for Bed Mobility, Transfers, Dressing and Toilet Use.
During initial round observation on 11/14/2023 at 5:08AM, this investigator stood in the hallway in front of
Resident #1's room and observed Certified Nursing Aide (CNA) A performing incontinent care on Resident
#1 with the door open and no curtain used for privacy, exposing Resident #1's naked body from the waist
down. Resident #1's bed was closest to the open door and the bed was visible from hallway.
No interviews were able to be conducted on 11/14/2023 with Resident #1 due cognitive impairment and
was non-interviewable.
Interview with CNA A on 11/14/2023 at 5:27am, she stated she had been working about 4 months with the
facility as a CNA. CNA A stated, it was important for residents to have privacy because it was their right and
she was nervous. CNA A stated, she forgot to provide privacy and thought she could be done before
anyone passed by. CNA A stated she was in-serviced on resident rights about a couple of months ago but
could not remember exact date.
Interview with Director of Nursing (DON), on 11/14/2023 at 11:03AM stated residents have the right to have
privacy, so no one sees their treatments, care, or overhear the medications they are receiving. DON stated
resident rights are important and was part of the facility's policy and DON ensures
(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:
675850
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
675850
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Portland
221 Cedar Dr
Portland, TX 78374
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 0583
training was done with all staff to ensure resident privacy/rights are understood and practiced.
Level of Harm - Minimal harm
or potential for actual harm
Interview with the Administrator on 11/14/2023 at 11:03AM stated, all residents' have a right of privacy,
dignity, and it was company policy that was frequently in-serviced on.
Residents Affected - Few
Review of In-service on Resident Privacy dated 11/14/2023 and in-service on Resident Rights-Resident
Has Right to Privacy dated 11/14/23. CNA A was present during this in-service.
Review of facility's Promoting/Maintaining Resident Dignity Policy dated 1/22 stated:
It is the practice of this facility to protect and promote resident rights and treat each resident with respect
and dignity as well as care for each resident in a manner and in an environment, that maintains or
enhances resident's quality of life by recognizing each resident's individuality.
1. All staff members are involved in providing care to residents to promote and maintain resident dignity and
respect resident rights .
12. Maintain resident privacy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675850
If continuation sheet
Page 2 of 2
