Avir At Converse
Avir at Converse in CONVERSE, TX — inspection on July 27, 2024.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the Administrator, [DATE] at 2:28 pm, the Administrator stated LVN A was terminated on [DATE].
The Administrator stated the Medical Director was notified of the incident at [DATE] at 12:02 pm and provided no further guidance.
The Administrator stated training for licensed nurses was initiated on [DATE] and was completed on the early morning on [DATE] and the training was completed by the DON.
Record review of document labeled, Employee Disciplinary Action Form, dated [DATE], revealed the name of LVN A, type of offense is listed as violation of company policy.
The document revealed LVN A as suspended on [DATE] at 11 pm and was terminated due to the result of the event on [DATE].
Record review of staff roster dated [DATE] reflected 13 licensed nurses (11 full time nurses and 2 prn nurses).
Record review of an in-service training attendance roster, dated [DATE], reflected the in-service topics included hospice resident and code status, resident rights and where to find code status.
The instructor was facility DON and roster was signed by 16 nurses (3 agency employees).
Documents attached to the in-service included an action tree describing how to respond when a resident is found with no pulse or unresponsive and listed the first action as go to [EMR name] and check code status.
Record review of a document titled Hospice Residents/Code Status/Resident Rights Post Test listed 4 questions which included 1.
What do you immediately check when a patient is found unresponsive? 2.
Can you be on hospice and still be a full code? 3.
Where do you find the code status? 4.
Resident has the right to decide their code status True or False?.
There are 18 (13 facility nurses and 5 agency nurses) completed posttests by nurses.
Record review of a Hospice list, dated [DATE], reflected 10 resident names. 3 residents are listed as full code.
675452
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 675452 B.
Wing 07/27/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rosewood Rehabilitation and Care Center 7700 Mesquite Pass Converse, TX 78109
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.