Health inspection·May 16, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately or no later than 24 hours for one (Resident #1) of four residents reviewed for abuse and neglect, in that: The facility failed to report to HHSC an allegation that Resident #1 was overdosed with opioid medication. This failure could place residents at risk of abuse or neglect. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, paranoid schizophrenia, major depressive disorder, history of heart attack, hypertension (high blood pressure), chronic pain, and age-related physical debility. Review of Resident #1's quarterly MDS assessment, dated 05/04/24, reflected a BIMS of 6, indicating a severe cognitive impairment. Section J (Health Conditions) reflected he had occasional pain and received PRN pain medication. Review of Resident #1's quarterly care plan, revised 02/05/24, reflected he experienced severe/almost constant pain at times with an intervention of administering medications as ordered by physician. Review of Resident #1's physician order, dated 02/08/24, reflected Fentanyl Transdermal Patch 72 Hour 25 MCG/HR - Apply 2 patches trans dermally every 72 hours for pain related to chronic pain syndrome. Review of Resident #1's physician order, dated 04/29/24, reflected Fentanyl Patches were discontinued. Review of Resident #1's progress notes in his EMR, dated 04/28/24 at 10:45 AM and documented by LVN A, reflected the following: After breakfast, CNA report [Resident#1] has a white substance in his mouth - nothing missing from his tray. [Resident #1] unable to swallow. Cleaned out mouth. He is difficult to arouse. Grip strength intact - able to follow that command. Able to follow finger with right eye, but he is not opening (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: 675980 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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)