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 Page 1 of 2 675452 675452 03/23/2025 Avir at Converse 7700 Mesquite Pass Converse, TX 78109

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall on 3/15/2025, at which time the Care Plan was revised to add fall risk. Interventions included having call light in rieach and answered promptly, encourage use of non-slips foorwear, and encouarge resdient to change positions slowly. During an interview with the DON on 03/23/2025 at 10:42 a.m., the DON stated Resident #1's admission fall risk assessment showed him to be a high fall risk, and risk for falls should have been addressed in his Comprehensive Care Plan but it had not been added until he had an actual fall. The DON stated the MDS-Nurse, LVN-A, was responsible for completing the initial and quarterly Care Plans, but she was also responsible for ensuring all needs are addressed in a Resident's Care Plan. The DON stated, it just got missed and they were very busy, and noted she had to work the floor more, as she had some staff turnover. The DON stated it was important all of a resident's needs were included in the Care Plan along with needed interventions, so all of a resident's health and safety needs could be addressed. Telephone interview on 03/23/2025 at 11:30a.m. with LVN-A revealed she was the MDS Nurse and she was responsible for the initial and quarterly Care Plans. After reviewing Resident #1's initial fall risk assessment showing he was at high risk for falls, LVN-A stated high risk for falls should have been included and addressed in his Comprehensive Care Plan and she did not know how she missed it, other than stating they have been very busy. Record review of the facility's undated policy, titled Fall and Post-Fall Management revealed Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety Develop interventions to address residents identified as at risk for falling and implement interdisciplinary plan of care. Interventions should be based on level of risk. Record review of the facility's undated policy titled Comprehensive Care Plans revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' 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 The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. 675452 Page 2 of 2