Avir at Fredericksburg

Inspectors wroteBased on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for two of six residents (Resident #1 and Resident #2) reviewed for clinical records. The facility failed to ensure Resident #1 and Resident #2 medical records included provider, psychiatric referrals, and visits following physical aggression incidents. The facility failed to ensure Residet #1's and Resident #2 medical record included quarterly Interdisciplinary Team Meeting (IDT) with the PASARR Service Coordinator regarding their current mental status and service needs. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that Resident #1 was free of significant medication errors for 1 of 3 residents (Resident #1) reviewed for medication errors. - LVN A administered Resident #2's medications to Resident #1. Resident #1 had a change of condition (slow respirations and low oxygen saturation levels) and was sent to the hospital via 911 EMS where she was diagnosed and treated for opioid overdose.- LVN A did not administer Resident #2's daily 4:00 PM prescriptions. A past non-compliance Immediate Jeopardy (IJ) was identified at 1:50 p.m. on 5/27/2026. The immediacy began on 5/24/2026 and ended on 5/25/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was completed in a timely manner and included pain he experienced, code status, ADL functional status, bladder/bowel incontinence, cognitive loss, skin risk, diet orders, or psychotropic drug use. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and that were not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #29) reviewed for freedom from physical and chemical restraints. The facility failed to ensure Resident #29 was free from physical restraint when nursing staff physically restrained her for medication administration on 06/02/25, 06/04/25, and 06/17/25. These deficient practices could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services to meet the needs for 5 of 9 residents (Residents #4, #5, #9, #15, and #134), and the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconcilitation for 1 of 9 residents (Resident #4) reviewed for medication administration. 1. The facility failed to ensure accurate documentation of medications administered to Resident #134. 2. The facility failed to ensure Residents #4, #5, #9, and #15 received medications as ordered by the physician. 3. The facility failed to prevent the loss of 2 tablets of Resident #4's hydrocodone-acetaminophen, a narcotic pain medication. 4. The facility failed to discard expired insulin for Resident #15. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This failurecould place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Record review of the staff roster revealed DM's hire date was 6/24/2024. [...]

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 1 of 1 facility reviewed. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label the drink containers in the dining room, which were used by residents for hydration. 2. The facility failed to store raw protein food items below fully cooked foods in the freezer. 3. The facility failed to not store personal beverages in the food preparation area. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for 2 of 3 staff members (CNA G and CNA I) reviewed for pre-employment TB screenings, 3 of 3 staff members (CNA G, CNA I, and LVN E) reviewed for pre-employment vaccinations, and 2 of 2 residents (Resident #5 and Resident #134) reviewed for transmission-based precautions. 1. The facility failed to screen staff members CNA G and CNA I for TB prior to hire, per CDC guidelines. 2. The facility failed to offer a vaccination for hepatitis B upon hire to staff members CNA G, CNA I, and LVN E per OSHA and CDC guidelines. 3. The facility failed to utilize proper PPE procedures during TBP for Resident #5 and Resident #134. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29 was prescribed and received the antipsychotic medication Haldol for disorganized schizophrenia without evidence in her medical record of the state consent form 3713. The deficient practices could place residents at risk for side effects for which they did not consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 residents (Resident #10) reviewed for assessment accuracy. The facility inaccurately assessed Resident #10 as not requiring a mechanical lift for transferring in the quarterly MDS submitted on 1/22/2025. This failure could lead to residents not receiving required care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Residents #29) reviewed for care plans. The facility failed to develop care plan interventions to include Resident #29 needing a therapeutic hold for medication administration. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #18) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received appropriate care and treatment for the indwelling catheter device placed after admission. 2. The facility failed to ensure Resident #5's foley catheter was secured appropriately. This failure could lead to infection or injury. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for all nursing staff in 1 of 1 facilities where therapeutic holds were used. The facility failed to ensure nursing staff were trained to therapeutically hold Resident #29 for medication administration. This failure could place residents at risk for harm due to staff who lack the appropriate skills and competencies to provide and minimize infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (200-300 halls cart) reviewed for medication storage. The facility failed to label the expiration dates of opened/unrefrigerated insulin stored in the medication cart for Resident #2. This failure could lead to ineffective insulin therapy, hyperglycemia, and illness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29's June MAR did not reflect that RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG was given on 06/04/25 and 06/17/25. The deficient practices could place residents at risk for side effects for which they did not consent.

Inspectors wroteBased on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident. These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 (Residents #11, #15, and #18) of 20 residents reviewed for dignity. 1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged. 2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges. 3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 7 of 20 residents (Residents #11, #15, #16, #19, #21, #22, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #11's incontinence was reflected in his care plan. 2. The facility failed to ensure Resident #15's pacemaker information was in his care plan. 3. The facility failed to ensure Resident #16's bowel incontinence was reflected in her care plan. 4. The facility failed to ensure Resident #19's did not have a care plan for handrails in bed. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (residents #21, and #22) of 20 residents reviewed for care plans. 1. Resident #21's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 03/17/24 to reflect she had taken antianxiety medication. 2. Resident #22's comprehensive person-centered care plan was not revised or updated based on the facility policy to not use chair and bed alarms for prevention of fall, but the care plan reflected continually using chair and bed alarms. These deficient practices affect residents who receive assessments and could result in an inaccurate comprehensive person-centered care plan and missed care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 (Residents #6, #16, #26, and #134) of 20 residents reviewed for competent nursing care. 1. CNA G failed to spread and cleaned within Resident #6's labial folds after an incontinent episode. 2. CNA A applied barrier cream to Resident #16's open wounds. CNA A reapplied Resident #16's wound dressing that had fallen off into the soiled brief. 3. LVN D failed to follow facility procedure when she instilled eye drops for Residents #26. 4. LVN C crushed medications for Resident #134, that were noted to be Do Not Crush. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure Menus and nutritional adequacy. Menus must Meet the nutritional needs of residents in accordance with established national guidelines.; Be prepared in advance; Be followed for 1 of 1 kitchen, in that: 1. Food items were not in the kitchen, pasteurized eggs or shelled eggs, bananas, bread and onions. Resident #29 and #17 preferred fried eggs. Resident group stated they would prefer fried eggs (#17, #24, #13) and Resident #18 preferred hard-boiled eggs for chef salad . 2. Kitchen cook J served residents for breakfast 1 slice of bacon, instead to two slices. Resident #2, #4, #13, #24, #29 had 1 slice of bacon for breakfast. 3. The facility failed to post of the weekly at a glance menu. [...]

Inspectors wroteBased on interviews, and record review the facility failed to ensure each resident receives and the facility provides-Food that accommodates resident preferences for 5 of 16 (#13, #17, #18, #24 and #29) reviewed for preferences, in that: Residents #13, #17, #18, #24 and #29 were not served their preferences. No documentation of dietary assessment with preferences. This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal spa: the failure to ensure residents were made aware of how to obtain a snack when desired for 4 of 9 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. [...]

Inspectors wroteBased on observation, interview, and the facility failed to ensure garbage was disposed of properly for 1 of 1 facility, in that: The area near the facility's two dumpsters was on dirt and not concrete slab . This deficient practice could lead to an unsanitary environment and encourage the presence of pests.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (#16, #29 and #134) of 20 residents reviewed for infection control, in that:. 1. CNA A, and CNA E failed to follow EBP signage instructions for Resident #16 by not sanitizing hands prior to entering or reentering Resident #16's room, and CNA #16 put the dirty dressing back onto Resident #16's buttock wound after the dressing fell onto the dirty brief during incontinent care. RN F performed a dressing change for Resident #16 without wearing a gown. 2. The facility failed to have signage on Resident #29's room door to indicate he was on EBP. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the maintenance of mechanical, electrical, and patient care equipment in safe operating condition for 3 (Residents #11, #15 and #18) of 20 residents reviewed for safe environment, in that:. 1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged. 2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges. 3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. These deficient practices could affect residents who rely on facility equipment for mobilization and could result in skin tears or injuries.

Inspectors wroteBased on interviews and record review, the facility assessments failed to accurately reflect the resident's status for 2 (Resident #14 and #21) of 20 residents reviewed for assessments. 1. Resident #14's significant change MDS assessment with an ARD of 02/08/2024 inaccurately reflected the resident had significant weight loss, but she did not have significant weight loss. 2. Resident #21's quarterly MDS assessment with an ARD of 03/17/24 did not reflect she had a fall, and inaccurately reflected she was taking an antidepressant and diuretic. These deficient practices affect residents at the facility who require assistance with services and ADL's and could result in missed or inaccurate care.

Inspectors wroteBased on interviews and record review the facility failed to ensure that when the facility anticipated discharge, a resident must have a discharge summary that included, but was not limited to, the following: A recapitulation of the resident's stay that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 (#31) closed records. Resident #31's discharge summary was not signed by a physician. This could affect all discharge residents and could result in record errors.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident choices for 1 (Resident #16) of 20 residents observed for quality of care. The facility failed to obtain an order for barrier cream to be applied to Resident #16's buttocks and peri area after incontinent care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #6) reviewed for incontinent care. CNA G failed to spread and clean within Resident #6's labial folds after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 11.54%, based on 3 errors out of 26 opportunities which involved 1 of 6 residents (Resident #134) reviewed for medication administration and medication errors. LVN C crushed 3 medications, 2 capsules and 1 tablet that were on the Do Not Crush list during medication pass for Resident #134. This deficient practice places residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1 out of 6 residents (Resident #134) were free of any significant medication errors whenobserved for medication pass. LVN C crushed 3 medications for Resident #134 that had Do Not Crush labeled on them during medication administration pass. This deficient practice affects residents with medications that are not recommended to be crushed and could result in physical harm or distress.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility, in that: The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure Food prepared in a form designed to meet individual needs for 1 of 8 (#2) residents, in that: Resident #2 was served a puree meat, instead of mechanical soft. This could affect all resident with diet orders that were prescribed by a physician and could result in residents not served the correct diet texture.

Inspectors wroteBased on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 10 of 10 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 210, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 210, 211, 315, and 317 did not have the required 80 square feet per resident. This deficient practice could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.

Inspectors wroteBased on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) whose records were reviewed for infections. The facility failed to follow protocols when Resident #1 was diagnosed with Salmonella: a. There was not a physician's order or a sign on Resident #1's room to inform nursing staff and others he was on contact precautions for an infection. b. The ADM and DON did not contact the local state authority or HHSC to report Resident #1 was diagnosed with Salmonella. These deficient practices could affect any resident and contribute to the spread of infections.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that: The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on 02/20/2023 and 02/21/2023, Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that: Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file. Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse (RN) to serve as DON on a full-time basis in that: - The facility had no full time Director of Nurses (DON) from October of 2022 through present [3/22/23]. This failure could place all residents at risk for not receiving necessary care and services.

Inspectors wroteBased on interviews and record review, the facility failed to employ or contract with a qualified social worker for a facility of 120 beds or less for 1 of 1 facility in that: The facility failed to ensure an employed or contracted social worker visited the facility as needed. This failure could place all residents at risk for not receiving necessary social services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure proper food storage of dry goods and fresh produce. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness.

Inspectors wroteBased on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 1 of 1 Activities Director Care Plan Coordinator, reviewed for training as the care plan coordinator, in that: The facility failed to train the Activities Director in the assigned job as the care plan coordinator. This failure could place residents at risk for harm by not having a complete and accurate care plan to support the residents needs and preferences.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 24 Residents (Resident #13) reviewed for injuries of unknown origin, in that: The facility failed to report an injury of unknown origin to the state agency when Resident #13 was discovered with a large bruise over her chest and around her back . Resident #13 could not state how she developed the bruise, and no one witnessed the development of the bruise. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the Resident's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that: 1. Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures. This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: - The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 24 residents (Resident #30) reviewed for accurate medical records, in that: LVN A failed to document an order for a urinalysis laboratory test ordered for Resident #30. This failure could place residents at risk for harm by inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident. These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living.