Health inspection·July 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 5 residents reviewed for care plans, (Resident #1). Resident #1 did not have a fall mat in place when he was found on the floor on 6/30/25. His care plan dated 5/9/25 indicated he was to have a fall mat. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #1's undated face sheet indicated he was a [AGE] year-old male that admitted [DATE] with diagnoses that included: Cerebral infarction (a stroke, death of brain tissue caused by a blockage of blood flow to the brain leading to lack of oxygen to the brain), mild cognitive impairment due to unknown etiology (subtle but measurable decline in memory and thinking), metabolic encephalopathy (a brain disorder caused by an underlying systemic illness affecting the body's metabolism characterized by changes in mental status, including confusion, memory problems, and altered behavior), and hemiplegia and hemiparesis affecting left dominant side (mild or partial weakness to complete paralysis of one side of the body). Record review of the significant change MDS dated [DATE] indicated Resident #1 had a BIMS score of 0, indicating severe cognitive impairment. The MDS indicated he had behavioral symptoms daily that was not directed toward others. He was totally dependent on staff for transfer. Record review of the care plan dated 5/9/25 indicated Resident #1 was a risk for falls and the interventions were: place bed in lowest position, fall mat, therapy screen, resident to be up in common areas. Record review of an Unwitnessed Fall Report dated 6/30/25 indicated Resident #1 was found lying in the floor at bedside on his left side. Fall mat was not at bedside. CNA (unknown) moved the fall mat while feeding lunch and did not return it afterwards. No visible injuries noted, but resident reported left knee pain. Fall mat placed at bedside. Bed left in lowest position. Neurological checks were initiated. MD, DON, ADM, and family notified. During an interview on 7/28/25 at 1:12 PM, LVN A said she assessed Resident #1 after he was found in the floor on 6/30/25. She said the bed was low, but the fall mat was not there. The bed was against one wall and the fall mat was propped up against the other wall. Someone had moved it and not put it back. She said she assessed him and saw no skin tears or injuries; however, he said his left knee hurt. He refused any medication for pain. She said when she left her shift that day (6/30/25) the X-ray technician was there to get the X-ray of Resident #1's knee. During an interview on 7/28/25 at 3:35 PM, LVN C said she saw Resident #1 on 6/30/25 and assisted LVN A to assess him after he was found in the floor. He had no skin tears or visible injuries. He said his left knee was hurting. She said she did not notice where the fall mat was, but it was not where Resident #1 was found or on the floor near him. She said the fall mat should have been by his bed because that Page 1 of 2 455678 455678 07/29/2025 Avir at Longview 301 Hollybrook Dr Longview, TX 75605

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was one of the preventions for an injury if he fell. She said she had no idea who moved the fall mat. During an interview on 7/29/25 at 8:58 AM, CNA D said sometimes she would move a resident's fall mat when she fed them, but it was important to move the fall mat back to prevent an injury to the resident if they fell. She said she knew the importance of a fall mat. She said the fall mat at bedside was part of the resident's care plan. During an interview on 7/29/25 at 9:03 AM, CNA B said a fall mat was placed at a resident's bedside to help to prevent an injury if they fell and it was important for resident safety. He said he always put a resident's fall mat back if he had moved it. During an interview on 7/29/25 at 9:48 AM, ADON E said Resident #1 was found in the floor on 6/30/25. He had a knee X-ray because he said his knee was hurting. His knee X-ray was negative for fracture. ADON E said his fall mat was not in place to the best of her knowledge on 6/30/25. She said the notes she read indicated the fall mat was not where it should have been. It was important that Resident #1's fall mat be there to keep fall preventions in place. She said a fall mat could cushion a fall and possibly prevent a fracture or injury. During an interview on 7/29/25 at 10:06 AM, RNC said Resident #1 was found in the floor 6/30/25. She said his fall mat was not on the floor near his bed, and he was not on the fall mat. She said a CNA had moved the fall mat, but she did not know who. She said fall mats can sometimes prevent a fracture. Fall mats are there as an extra precaution. She said Resident #1 was care planned for a fall mat, but staff [BH1] were not following their care plan. RNC said a risk of a fall mat not being where it should, was fracture and a risk of any other kind of injury. During an interview on 7/29/25 at 10:41 AM, the ADM said Resident #1 was found in the floor on 6/30/25 and was assessed by LVN A. She said his knee was hurting and they got an x-ray of his knee which showed no fracture. The fall mat was not in place on 6/30/25 when Resident #1 was found in the floor. She said since the fall mat was not in place, he did not have anything soft to land on. The risk of not having his fall mat placed properly was injury. The ADM said Resident #1 was care planned for the fall mat and staff [BH2] did not follow the care plan. They did not know who moved the fall mat and did not return it to the floor beside Resident #1's bed. Record review of an X-ray report for Resident #1 dated 6/30/25 indicated he did not have a fracture of his knee. He had moderate osteoarthritic (arthritis) changes in his left knee. Record review of a Care Plans, Comprehensive Person-Centered Policy dated March 2022 indicated: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7.The comprehensive, person-centered care plan: b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:a.provided by qualified persons. 455678 Page 2 of 2