Health inspection·March 23, 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 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 were identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's high risk for falls which was identified in his admission fall risk assessment, and failed to include a care plan regarding how to prevent falls. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans. The findings included: Record review of Resident #1's face sheet, dated 03/23/2025, revealed a 74- year- old male, who was admitted to the facility on [DATE] and with re-admission on [DATE]. Resident #1 had diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes it difficult to breathe); Respiratory Failure (occurs when the lungs can't properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood); Atrial Fibrillation (irregular, often rapid heart rate that can cause poor blood flow), and Diabetes Mellitus Type 2 (disease that results in too much sugar in the blood). Record review of Resident #1's admission MDS assessment, dated 02/17/2025, revealed Resident #1's BIMS score was 2 which indicated severe cognitive impairment. Resident #1 was assessed as requiring substantial/maximal assistance (Helper does more than half the effort) for chair-to-bed transfer and lying to sitting on side of bed. Record review of Resident #1's admission fall risk assessment dated [DATE] revealed a total score of 10 or greater which ndicated a high risk for falls. Record review of Resident #1's comprehensive care plan, dated 02/20/2025, revealed a focus area Resident is at risk for falls due to unsteady gait, decreased balance, medications, poor safety awareness. Resident uses a mobility device. Requires assistance with Transfers. Fall risk score moderate/severe. The initiation date for this focus area was 3/17/2025, 2 days after Resident #1 had an actual (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: 675452 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 675452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Converse 7700 Mesquite Pass Converse, TX 78109 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)