Health inspection·March 28, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that: Residents Affected - Few CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 3/27/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #6's face sheet, dated 03/27/2025, revealed an admission date of 03/14/2014 and, a readmission date of 05/18/2021 and, a readmission date of 11/09/2024, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #6's Annual MDS assessment, dated 02/07/2025, revealed the resident had a BIMS score of 3, indicating he was severely impaired. Resident #6 was frequently incontinent of bowel and bladder. Record review of Resident #6's care plan, dated 05/31/2022, revealed a problem of I have an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: impaired cognition, muscle weakness, impaired balance,, with an intervention of TOILET USE: Resident is limited to extensive care for toilet use/Incontinence management. They do not participate in process. Provide incontinence checks every 2 hours and PRN. Provide incontinence care as needed and position for comfort after care Resident does attempt to toilet self. Observation on 03/27/2025 at 1:50 p.m. revealed CNA A and CNA B did not completely close the privacy curtain while they provided incontinent care for Resident #6, exposing the resident's genital area during care. The resident's end of the bed was completely uncovered and the resident's roommate was in the room at the time of care. During an interview with CNA A and CNA B on 03/27/2025 at 1:56 p.m., CNA A and CNA B confirmed the privacy curtain was not completely closed while they provided care for Resident #6 but it should have been. They confirmed they received resident rights training within the year. During an interview with the DON on 03/27/2024 at 2:30 p.m., the DON confirmed privacy must be Page 1 of 4 675452 675452 03/28/2025 Avir at Converse 7700 Mesquite Pass Converse, TX 78109

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provided during nursing care and Resident #6's privacy curtain should have been closed completely. She confirmed the staff had received training on resident rights within the year and the training was provided by the ADON and herself. They also checked the staff skills annually and as needed. Review of the facility's policy titled Privacy, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed [ .] 675452 Page 2 of 4 675452 03/28/2025 Avir at Converse 7700 Mesquite Pass Converse, TX 78109

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #7) reviewed for accuracy of medical records in that: 1. a. The facility failed to have an accurate fall risk assessment for Resident #7 when the resident had 4 falls between February and August 2024 and the assessment on 08/19/2024 indicated Resident#7 was at low risk. b. The facility failed to accurately document neuro checks for Resident #7 for every 30 min Neurological checks times 3 after the fall on 09/17/2024. This deficient practice could place residents at risk for errors in care and treatment. The findings included: 1. Record review of Resident #7's face sheet, dated 03/28/25, revealed Resident #7 was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline in cognitive abilities), Flaccid Hemiplegia (Complete lack of voluntary movement in a limb), Dysphasia (Difficulty swallowing), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood) , Hypertension (High blood pressure). Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS of 9, indicating the resident was moderately cognitively impaired. Further review of this MDS revealed the resident had a fall since the prior assessment. a. Review of Resident #7's Fall risk assessment dated [DATE] revealed Resident #7 was at low risk for falls. Further review revealed under History of falls within last six months, no history of falls noted/reported. Review of Resident #7's incidents log from 12/2/2022 to 03/18/2025 revealed, between February 2024 and August 2024, Resident #7 had 4 falls. During an interview with the DON on 03/28/25 at 10:45 a.m., she confirmed the resident had falls between February 2024 and August 2024 and the falls risk document dated 08/19/2024 was inaccurate. She stated Resident #7 was a moderate to high risk for fall. She added the fall prevention interventions in place to prevent further fall for Resident #7 had not been changed after the assessment. Record review of facility's policy, titled purpose and requirements medical records, dated 2015, revealed The medical record is a legal document that serves the purpose of: 1. providing an accurate assessment of each resident's condition. During an interview with the DON on 3/28/2025 at 3:00 p.m., she stated there was no policy regarding the accuracy of clinical record and assessment. She added the ADON and herself checked the records for accuracy frequently. 675452 Page 3 of 4 675452 03/28/2025 Avir at Converse 7700 Mesquite Pass Converse, TX 78109

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. Review of Resident #7's clinical record and progress notes revealed the resident had an unwitnessed fall on 9/17/2024. Further review revealed documentation of neurocheck at 1 hour after the fall were documented but there were no record of neurocheck at 30 minutes time 3. During an interview with the ADON on 03/28/25 at 12:41 p.m., she stated the nurse providing care for Resident #7 at the time of the fall had told her the next morning the neurocheck had been done but she had to document in the electronic record. The ADON stated and confirmed the documentation was not done accurately. During an interview with the DON on 3/28/2025 at 3:00 p.m., She confirmed the documentation of the neurocheck for Resident #7 after the fall on 09/17/2024 was not done accurately. She stated they had in serviced the staff to ensure all care provided was accurately documented. Further interview revealed the facility did not have a policy regarding the accuracy of clinical record. She added the ADON and herself checked the records for accuracy frequently. 675452 Page 4 of 4