Inspection·March 13, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement written policies and procedures that ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made for 1 of 5 residents (Resident #1) reviewed for reportable incidents. On 3/2/2024, Resident #1 had an unwitnessed fall with a laceration on the head requiring staples and the facility failed to report it to State Agency. This failure can result in physical or mental harm, physical or mental decline, and continued patient neglect. Findings include: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Diagnoses included but were not limited to Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), repeated falls, major depressive disorder (persistent feeling of sadness and loss of interest), and muscle weakness. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. This MDS documented that Resident #1 had had two falls with no inuries. Record review of Resident #1's care plan updated 3/8/24 revealed a goal that the resident would remain free of injuries and falls. Interventions included assess footwear for proper fit and non-skid soles or socks, wander alarm, physical therapy referral, encourage use of call light, instruct resident on safety measures and keep call light within reach. Record review of Resident #1's event report, dated 3/2/24, reflected Resident #1 had an unwitnessed fall with a laceration to the back of the head. Record indicated Resident #1 was transferred to hospital for evaluations and treatment. Record review of resident's progress note written by ADON, dated 3/12/24, reflected the ADON removed staples from resident. In an interview on 3/13/24 at 3:24 PM, the FM of Resident #1 stated Resident #1 fell and hit her head a couple of weeks ago. The FM stated Resident #1 had to go to the emergency room. (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: 455989 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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)