Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to maintain medical records in accordance with accepted
professional standards and practices for 1 (CR #1) of 4 residents reviewed for medication administration.
1-LVN A and LVN B documented CR #1 was being monitored for behaviors and medication side effects and
documented CR #1 was administered medication in the evening of 12/27/2024 and the day of 12/28/2024
while he was at the hospital.
2-LVN A documented CR #1 had a pain level of 3 (on a scale of 0-10, with 10 being the most pain) on
12/29/2024 while he was at the hospital.
This failure could possibly lead to resident injury due to inaccurate documentation and reflection of resident
health and care.
Findings included:
Record review of CR #1's face sheet last captured 12/29/2024 revealed a [AGE] year-old male originally
admitted on [DATE]. His medical diagnoses included: Bipolar Disorder, Unspecified Dementia,
Hypertension (high blood pressure), muscle wasting and atrophy, Diverticulitis of the intestine, slow transit
constipation and congestive heart failure. He was discharged on 12/27/2024.
Record review of CR #1's Quarterly MDS (a resident assessment screening tool) dated 10/25/2024
revealed a BIMS (Brief Interview of Mental Status) score of 3, indicating severe impaired cognition. CR #1
required moderate assistance with eating and oral hygiene, and required substantial to maximal assistance
with toileting, showering, dressing, putting on and taking off footwear, and personal hygiene.
Record review of CR#1's care plan last updated 10/25/2024 revealed CR #1 had potential to have
behaviors due to his poor cognition due to Dementia, with interventions including: administering
medications as ordered, analyzing times of day, places, circumstances, triggers, and what de-escalates
behavior and documenting, and providing physical and verbal cues to alleviate anxiety. CR #1 also had a
history of having Dementia and took a routine antipsychotic medication, putting him at risk of side effects
with an initiated date of 3/2/2023, and interventions including: monitoring, documenting, and reporting PRN
any adverse reactions of Psychotropic medications such as unsteady gait, frequent falls, diarrhea, muscle
cramps, nausea, behavior symptoms not usual to the person.
Record review of CR #1's progress notes dated 12/27/2024 at 8:00 am revealed 911 was called at
(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 3
Event ID:
676252
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
676252
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Capstone Healthcare Estates at Veterans Memorial
1424 Fallbrook Drive
Houston, TX 77038
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 0842
Level of Harm - Minimal harm
or potential for actual harm
8:03am and CR #1 was transported to the ER. CR #1's RP (Responsible Party, the person who can make
decisions for a resident) was notified and was aware, and the DON was notified of the incident as well. A
late entry note created 12/29/2024 at 4:40pm revealed CR #1 was sent to the ER due to a change in
condition of Respiratory arrest.
Residents Affected - Few
Record review of Resident #1's Medication Administration Record for December 2024 revealed:
-Antidepressant Monitoring for Sertraline and Trazadone every shift for side effects with a start date
07/21/2023 was marked as No for behaviors documented on 12/27/24 6pm-6am shift and signed by LVN B,
and for behaviors documented on 12/28/2024 6am-6pm shift and signed by LVN A.
-Behavior Monitoring for Antidepressant Medication: Sertraline Document # of Times Resident has
Exhibited the Above Behavior During Shift and Intervention Codes: with a start date of 6/5/2023 was
marked No for behaviors documented on 12/27/24 6pm-6am shift and signed by LVN B, and for behaviors
documented on 12/28/2024 6am-6pm shift and signed by LVN A.
-Monitor for signs and symptoms of adverse reaction: Interocular hemorrhage, abdominal pain, flatulence
.ASPIRIN every shift with a start date of 07/02/2024 documented as completed/administered on 12/27/24
6pm-6am shift and signed by LVN B, and as completed/administered on 12/28/2024 6am-6pm shift and
signed by LVN A.
-Pressure Reducing Mattress to bed every shift with a start date of 2/22/2023 document as
completed/administered on 12/27/24 6pm-6am shift and signed by LVN B, and as completed/administered
on 12/28/2024 6am-6pm shift and signed by LVN A.
-Senna-Plus Oral tablet 8.6-5.0 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day
for constipatin [sic] with a start date of 4/30/2023.
Record review of CR #1's SNF/NF to Hospital Transfer Form revealed LVN A documented that 12/29/2024
at 4:44pm CR #1 had a pain level of 3. The form also noted that CR #1 was transferred from the facility to
the hospital on [DATE] at 8: 15am.
Interview with LVN A on 1/2/24 at 11:15am, she said 6am to 6pm was her normal shift. She said she
documented in CR #1's nursing progress notes that he was sent to the hospital and clicked on No for all his
orders. She would review his Orders and can make Late Entry notes to correct any incorrect
documentation.
Interview with the DON on 1/2/24 at 1:17pm, she said that LVN A and LVN B should have documented that
Resident #1 was in the hospital and not documented medications as given. The DON said that not
accurately documenting that information could delay the resident's treatment. When asked what risk it could
have posed to CR #1 if medications were documented as given when it was not, she said, I don't know how
else to answer that. The DON called back later and said that LVN A will do a late entry in the system, and
that LVN B will do so as well, and that she would conduct individual in-services for both nurses on
medication documentation.
Later interview with the Administrator and the DON on 1/3/24 at 3:03pm, the DON reviewed Resident #1's
MAR and stated that the Senna was the only medication that was incorrectly documented as given. The
DON also said she would begin conducting in-services on accurate documentation for the rest of her staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676252
If continuation sheet
Page 2 of 3
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
676252
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Capstone Healthcare Estates at Veterans Memorial
1424 Fallbrook Drive
Houston, TX 77038
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Record review of the facility's Pharmacy Services Overview policy last revised April 2019 revealed that
pharmaceutical services consist of the processes of receiving and interpreting prescriber's orders, including
distributing, administering, and monitoring response to medications, biologicals, and chemicals.
Record review of the facility's Documentation of Medication Administration policy last revised November
2022 stated, A medication administration record is used to document all medications administered and that
a nurse or certified medication aide documents all medications administered immediately after it is given.
The documentation is to include reasons why a medication was withheld, not administered or refused.
Event ID:
Facility ID:
676252
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 3, 2025 survey of Avir at Veterans Memorial?
This was a inspection survey of Avir at Veterans Memorial on January 3, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Avir at Veterans Memorial on January 3, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.