Inspection·December 7, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #1's off-loading boot, which was used to prevent skin breakdown, was placed on the resident. This failure could place residents at risk for the development of pressure injuries. Findings included: Record review of Resident #1's face sheet, dated 12/07/2023, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified psychosis (experiencing symptoms of schizophrenia or other psychotic symptoms), acute respiratory disease (affects the lungs, bronchus and respiration), blindness in right eye, pressure induced deep tissue damage on left heal (affects subcutaneous tissue under intact skin), hypothyroidism (underactive thyroid), lack of coordination, and cognitive deficit disorder. Record review of Resident #1's initial MDS, dated [DATE], reflected a BIMS score of 4, which indicated severe cognitive impairment. Resident #1 required one-person assist / supervision for transfers and bed mobility, was at risk for pressure ulcers, had an unhealed pressure ulcer, and required a pressure reducing device for the bed. Record review of Resident #1's comprehensive care plan, dated 10/20/2023, revealed Problem: skin concerns as evidenced by DTI (Deep Tissue Injury) to heel. Goal: area will heal without complications over the next 90 days. Approach: heel protector on left foot when resident in bed. Record review of wound care notes dated 11/29/2023 and signed by the DON, reflected a closed pressure injury on the left heel, 2 cm by 3 cm noting an off-loading required. Wound care notes dated 12/6/2023, signed by the DON, reflected a new of shiny tissue, 2 cm by 2 cm pressure injury on the left heel and an off-loading boot required. An observation and interview on 12/07/2023 at 9:39 AM with Resident #1 revealed he was in bed. His off-loading boot was placed on the dresser beside his bed. A sign above Resident #1's bed stated, Please put boot on left foot at all times while in bed. Resident #1 stated he had a wound on his heel but denied any pain. When the off-loading boot, on the dresser, was pointed out to him, he said he (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: 675270 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 675270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060 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)