Health inspection·April 5, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #6) reviewed for advanced directives in that: Resident #6 did not have advance directives documented in the admission agreement or electronic medical record from the date of admission, [DATE], to discharge date , [DATE]. This deficient practice could affect residents admit to the facility and place them at risk of not having their wishes known, which could delay emergency treatment. Findings included: Review of Resident #6's face sheet dated revealed he was a [AGE] year-old male was admitted into the facility on [DATE] with diagnoses including Alzheimer's Disease. Review of Resident #6's consolidated orders for [DATE] revealed resident had an order for Full Code status, initiated [DATE]. Review of Resident #6's admission care plan, initiated [DATE], revealed the resident had no advanced directives and no advanced directive care planning had been scheduled with the resident's representative. Review of Resident #6's record revealed the resident's representative did not sign the facility admission agreement that discusses advanced directives prior to admission or after the resident's admission to the facility. Interview on [DATE] at 10:22 a.m. with the Admissions Director revealed she met with the resident representative prior to admission and told the representative the admissions packet needed to be completed. She said she did not get the admission agreement signed prior to or during the residents stay at the facility. She said she tries to complete admissions packets with residents or their representatives prior to admission or the day they admit. She said the importance of doing this is so the facility has consent to treat and to establish advanced directives. She stated the company policy is to have admission agreement completed within 24 to 48 hours of admission. She further stated the advanced directive declination page of the admissions agreement is provided to nursing and the facility Social Worker once completed. (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: 676133 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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)