Health inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents review for resident rights. RN A failed to notify Resident #1's family when a new medication order for antibiotics, to treat a urinary tract infection, was initiated on 06/14/2024. This failure put residents at risk for not having their representative notified and aware of their current medical status. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine unspecified, pain unspecified, dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, acute kidney failure (a sudden and rapid decline in kidney function). Face sheet also reflected Resident #1 had a Responsible Party. Review of the quarterly MDS assessment for Resident #1 dated 06/12/2025 reflected a BIMS score of 3, indicating severe cognitive impairment. It reflected he had an indwelling catheter. Review of the care plan for Resident #1 initiated 06/05/2025 reflected the following: [Resident #1] has ADL Self Care Performance Deficit relating to dementia, impaired limited mobility, he had impaired cognitive function/dementia or impaired thought processes related to dementia, Bims. Interventions included: Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of Resident #1's MAR reflected: Sulfamethoxazole- Trimethoprim (Bactrim DS -is an antibiotic prescribed to treat various bacterial infection) Tablet 800- 160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days -Start Date- 06/14/2025. Review of Resident #'s progress notes dated 06/14/2025 at 10:05 pm created by RN A reflected: Note Text: The order you have entered Sulfamethoxazole-Trimethoprim Tablet 800-160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. Review of Resident #1's progress notes for 06/14/and 06/15/2025 did not reflect Resident #1's family was notified of a new antibiotic order for UTI. Review of Resident #1's NP's progress notes dated 06/16/2025 at 5:45 pm reflected: Acute UTI -urine cx collected 6/10/25, resulted 6/14/25 w/ +E. coli, 50-99k- d/t confusion and repeated falls treating for UTIBactrim DS 800/160 mg q12 ordered 6/14/25, ED 6/21/25 Review of Resident #1's progress notes dated 06/22/2025 at 10:58 am reflected Resident #1 was discharged home. During an interview on 07/09/2025 at about 2:19 pm, RN A stated she worked the 2-10 pm shift on the 700 and 800 halls. RN A stated her name was noted on Resident #1's antibiotic order because she confirmed the order put in by the NP. RN A stated the NPs usually put new orders in the computer and the nurses confirmed that they would start the order. RN A stated, I don't remember notifying the family or documenting on the antibiotic order. It was important to notify the family of new medication orders so they can know and sometimes the family would disagree with (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: 676345 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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)