Avir At Woodlands

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #44) of 5 residents reviewed for baseline care plan completion.The facility failed to complete Resident #44's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.Findings included:Record review of Resident #44's face sheet dated 08/12/2025 revealed a [AGE] year-old female admitted on [DATE REDACTED] with the following diagnoses fracture of femur, high blood pressure, atrial fibrillation (abnormal heart rhythm) and muscle weakness.Record review of Resident #44's admission MDS dated [DATE REDACTED] revealed in Section C - Cognitive Patterns revealed a BIMS score of 15 (cognitively intact).Record

review of Resident #44's electronic medical record revealed Resident #44's baseline care plan was initiated

on 08/13/2025. During an observation and interview on 08/12/2025 at 11:35 AM Resident #44 was sitting in her room in her wheelchair. Resident #44 stated she was at facility for breaking her hip.During an interview

on 08/13/2025 at 11:07 AM the RNC stated her expectation was that baseline care plans should have been completed within 48 hours of admission. The RNC stated she had initiated the baseline care plan for Resident #44 today. The RNC stated that the baseline care plan had not been completed in the required 48 hours. The RNC stated the charge nurse, and the DON were responsible for completing the baseline care plan. The RNC did not provide a reason for what to led to failure. During an interview on 08/13/2025 at 2:15 PM the DON stated her expectation was baseline care plans should have been completed within the 48 hours of admission. The DON stated the charge nurse was responsible for initiating the baseline care plan.

The DON stated what led to failure was oversight by staff. During an interview on 08/13/2025 at 3:30 PM

the ADMN stated her expectation was baseline care plans should have been completed within 48 hours of admission. The ADMN stated the charge nurse was responsible for completing the baseline care plan. The ADMN stated the DON was responsible for monitoring to ensure the baseline care plans were completed within 48 hours. The ADMN stated she did not think there was a negative effect on resident not having baseline care completed. The ADMN did not give a reason for the failure of Resident #44's baseline care plan completed. Record review of the facility policy titled, Care Plans-Baseline dated March 2022, revealed

A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

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

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(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0802 during a standard health inspection conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited Avir at Woodlands in EASTLAND, TX for a deficiency under regulatory tag F-F0809 during a standard health inspection conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Avir at Woodlands.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.