Health inspection·November 10, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for supervision.1. The facility failed to ensure CNA A followed 2-person assist as stated on Resident #1's care plan when she transferred Resident #1 from her wheelchair to bed on 11/01/25 at around 7:00 PM.2. The facility failed to ensure CNA A followed Resident #1's care plan and used a 2 person assist when she provided incontinent care on 11/01/25 around 8:30 PM and on 11/02/25 around 4:00AM. Which resulted in acute proximal and mid left lower leg fractures.An Immediate Jeopardy (IJ) was identified on 11/08/25. While the IJ was removed on 11/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of injuries and not receiving the appropriate level of assistance and care. The findings include:Record review of Resident #1's face sheet, dated 11/10/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease with late onset (progressive brain disorder that caused memory loss and difficulty with thinking, reasoning and daily tasks), age-related osteoporosis (disease that weakens bones) with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing and Other specified arthritis (inflammation or swelling of one of more joints), multiple sites. Record review of Resident #1's state optional MDS assessment, dated 08/12/25, reflected Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Resident #1 was coded as requiring two+ persons physical assist for transfers and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Record review of Resident #1's care plan, with an initiated date of 12/20/22, reflected Resident #1 was a 2 person assist for transfers, and bed mobility, with an initiated date of 12/20/22, and was a 2 person assist for incontinent care, with an initiated date of 05/15/23. Record review of Resident #1's notes, dated 11/01/25 at 10:19 PM, written by LVN B, stated Resident c/o pain to left leg, no noted abnormalities to leg medication given will continue to monitor. Record review of Resident #1's change in condition form, dated 11/02/25 at 5:30 AM, stated Resident #1 had uncontrolled pain and change in skin color or condition that started the morning of 11/02/25 and stated, Resident had c/o of leg pain upon assessment of leg it was noted that resident had discoloration to leg.Record review of Resident #1's skin assessment, with an effective date of 11/02/25 at 6:00 AM, completed by LVN B, identified bruising to the front of the left lower leg that was 10cm x 11cm and stated, Resident was noted to have discoloration to below knee. Discoloration was light green in color resident states pain to left lower extremity no redness or swelling noted. Record review of Resident #1's notes, dated 11/02/25 at 9:41 AM, written by LVN C, stated at 6:45 AM nurse practitioner returned call from LVN B and Page 1 of 9 675672 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ordered stat knee x-ray, LVN C requested left knee, tibia, ankle and foot x-ray due to left lower leg swelling, pain and purplish discoloration. Record review of Resident #1's order summary report included an order or stat x-ray of left knee, tibia, ankle and foot for pain and discoloration with an order date of 11/02/25. Record review of Resident #1's notes, dated 11/02/25 at 10:51 AM, written by LVN C, stated at 10:20 AM reflected x-ray results were received and showed acute proximal and mid left leg fractures and stated to send referral to orthopedic clinic and new orders were provided for tramadol. Record review of Resident #1's x-ray impressions of the left tibia and fibula from the exam taken on 11/02/25 stated, Acute proximal and mid left lower leg fractures. Record review of Resident #1's nursing note, dated 11/03/25 at 9:41 AM, by LVN C, reflected she followed up with the orthopedic clinic regarding the clinical faxed over on 11/02/25 and they confirmed they were received. Record review of Resident #1's nursing note, dated 11/03/25 at 11:25 AM, by LVN C, reflected MD E at orthopedic clinic would not be able to see Resident #1 due to location of fractures but would forward clinical paperwork to MD F. Record review of Resident #1's nursing note, dated 11/03/25 at 3:18 PM, by the DON reflected she notified the responsible party for Resident #1 that the orthopedic clinic was unable to see Resident #1 due to insurance and was made aware of the option to send her to the hospital for evaluation and treatment to which Resident #1's responsible party agreed to. Record review of Resident #1's order summary report included an order to send Resident #1 to the emergency room to evaluate and treat for acute proximal and mid left leg fractures, with an order date of 11/03/25. Record review of Resident #1's notes, dated 11/03/25 at 3:50 PM, by LVN C, reflected transportation was at the facility to transport Resident #1 to hospital. Record review of hospital CAT scan of Resident #1's left leg, dated 11/03/25, reflected the resident had a displaced mid-third tibial shaft fracture and a displaced comminuted mid-third fibular shaft fracture. Record review of CNA A's statement, dated 11/05/25, reflected CNA A completed a 1 person transfer of Resident #1 without the use of a gait belt and Resident #1 complained of pain after transfer when she was lying down in bed. CNA A's statement stated Resident #1 did not have a fall. Attempted interview with CNA A via phone on 11/07/25 at 1:55pm and 1:56pm was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with Resident #1's responsible party on 11/05/25 at 11:40am he stated Resident #1 would not be returning to the facility and was currently at the hospital waiting to go into surgery the following day. Resident #1's responsible party stated Resident #1 had been asked by family about what occurred to cause her injury, but she did not know. Responsible party for Resident #1 stated she was currently on a lot of medication and did not believe she was coherent enough to answer questions.During an interview with the DON on 11/07/25 at 4:15 PM, she stated on 11/05/25 they spoke with CNA A and got her statement and identified she completed a 1 person transfer with Resident #1 on 11/01/25. The DON stated they suspended CNA A after this was identified. The DON stated she asked CNA A if she checked her Kardex and stated that was when CNA A informed her she was having trouble logging into her POC to see her Kardex. At this time the DON was asked if she could assist in reaching CNA A as her phone appeared to be disconnected. DON stated she would attempt to reach her through social media and try to set up an interview. The DON set up a phone interview with CNA A for this surveyor on 11/07/25 at 5:30 PM, CNA A she stated she worked with Resident #1 on 11/01/25 from 6:00 PM to 6:00 AM. CNA A stated around 7:00 PM she completed a 1-person transfer of Resident #1 from the wheelchair to the bed. CNA A stated she was not aware Resident #1 was a 2 person assist and her level of assistance had changed while she was on leave. CNA A stated she returned from leave in July and had been transferring Resident #1 with 1 person assistance since. CNA A stated after she transferred Resident #1 to the bed she complained of pain to her leg but could 675672 Page 2 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not recall which leg. CNA A stated it was not uncommon for Resident #1 to complain of pain during transfers and usually when she would place Resident #1's legs into the bed she would complain of her back of legs hurting and she would inform the nurse. CNA A did not mention any incident occurring during the transfer and stated Resident #1 did not have a fall during her shift. CNA A stated on 11/01/25 around 8:00 PM, she notified LVN D of Resident #1 complaining of pain, and LVN D told CNA A she would inform LVN B who was the nurse for that hall when she got there. CNA A stated she was not aware of what medication Resident #1 received but did know she was on scheduled pain medication. CNA A stated around 8:30 PM on 11/01/25, she changed Resident #1 because she was wet and she continued to check on her every 2 hours and then changed Resident #1 again on 11/02/25 at around 4:00 AM. CNA A stated during both times she provided incontinent care to Resident #1, she provided 1 person assistance and she believed Resident #1 was a 1 person assist for incontinence care and for bed mobility and she had always used 1 person assistance for bed mobility. CNA A stated when providing Resident #1 care on 11/02/25 at 4:00 AM, she noticed Resident #1 had more pain and she had raised Resident #1's knee up to roll her and noticed she was not able to grab the rail and was saying Ow, ow. CNA A stated Resident #1 expressed pain to her knee and stated it was from her knee down to her toes. CNA A stated Resident #1 had not shown any signs of extreme pain until 4:00 AM. CNA A stated she put down Resident #1's leg and called LVN B to assess Resident #1, who was noted with discoloration to the left leg. CNA A stated she was trained over reviewing the Kardex for assistance levels in March 2025. CNA A stated she did not know what the facility policy stated in regard to following a resident's care plan. CNA A stated she did not cause any injury to Resident #1 because she had not complained of extreme pain until 4:00 AM on 11/02/25. CNA A stated she was currently not working at the facility due to being placed on hold for investigation purposes at work. During an interview with LVN D on 11/07/25 at 7:23 PM, she stated she worked on 11/01/25 from 6:00 PM to 6:00 AM but was not Resident #1's nurse. LVN D stated when she first arrived Resident #1 was in the dining room and the common area, and she did not have any discoloration to either leg. LVN D stated between 7:00 PM and 8:00 PM, CNA A put Resident #1 in bed and notified her of Resident #1 complaint of pain to left leg. LVN D stated when she went to see Resident #1, she was not in distress, did not have any bruising or discoloration and stated Resident #1 stated, my leg hurts. LVN D stated she had not documented anything since she did not find anything out of the ordinary. LVN D stated about 10 to 15 minutes after she saw Resident #1, she notified LVN B of Resident #1's pain to leg. LVN D stated she was not sure what LVN B did after she notified her, but she asked LVN B if she went to check Resident #1 and she told her, not yet. LVN D was not sure what time this was, but maybe it was around 12:00 AM. During an interview with LVN B on 11/08/25 at 11:25 AM, she stated she worked with Resident #1 on 11/01/25 from 6:00 PM - 6:00 AM. LVN B stated Resident #1 had chronic pain and at the start of her shift she complained of pain but could not recall the exact time CNA A notified her. LVN B stated she went to see Resident #1 in a timely manner after being notified but did not note anything to Resident #1's leg aside from her regular edema (swelling). LVN B stated she medicated Resident #1 with pain reliever at around 10:00pm. LVN B stated Resident #1 slept through most of the night. LVN B stated later that morning CNA A notified her Resident #1 did not want to get up and was in severe pain. LVN B stated she went to assess Resident #1 and noticed discoloration to her leg. LVN B said the discoloration was to the left leg and was slightly green and was not pinpointed to one area but was spread out. LVN B stated she noted the discoloration around 5:30 AM/6:00 AM. LVN B stated she thought it was unusual and asked the oncoming nurse, LVN C, if it was something that was there before. LVN B stated before she left her shift, she completed a change in condition, made notifications to the physician, Resident #1's 675672 Page 3 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few responsible party and informed the people she needed to inform as well as the oncoming nurse. LVN B stated she did not know how Resident #1's fractures occurred, and stated she asked CNA A if she bumped Resident #1 during turning or transfers and she told her no, everything was normal aside from when she started to complain of pain to the leg after she was put in bed. LVN B stated bruising and discoloration did not look like Resident #1 was hit but looked like a busted vein. LVN B stated Resident #1 had not had any incidents, accidents, falls or altercations that could have caused the injury to the left leg that she was aware of. LVN B was not aware how many staff Resident #1 required for transfers and stated she would have to check her chart. During an interview with the DON on 11/08/25 at 3:18 PM, she stated staff could find levels of assistance in the residents POC and they should be checking this before working with residents to confirm their assistance levels. The DON stated CNA A was trained over these procedures and she did not know if CNA A checked Resident #1's assistance levels on 11/01/25 prior to working with her. The DON stated she was made aware CNA A was having trouble logging into the system and she could have gotten assistance from any other staff member to view that information. The DON stated Resident #1 required 2-person assistance for transfers, bed mobility and incontinent care as per her care plan and CNA A should have used 2-person assistance when she provided this care. The DON state the charge nurses should be monitoring staff to ensure they were providing the proper assistance. The DON stated not providing the correct level of assistance could possibly cause injury. The DON stated she could not say how Resident #1 could have ended up fractures to her leg. The DON stated she did not personally think a 1 person assistance caused fractures to Resident #1 and stated Resident #1 had a rod in that knee and a diagnosis of osteoporosis and stated although they didn't know the degree of osteoporosis (disease that causes bones to become thin, wake and more likely to fracture), she thought it could have been because of the rod. Attempted interview with CNA A via phone on 11/09/25 at 5:04pm was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with the NP on 11/10/25 at 12:29 PM, she stated Resident #1 had osteoporosis and her bones were brittle, so she was a 2 person assist. The NP stated any tiny trauma or being transferred by only 1 person could cause a fracture. During an interview with LVN B on 11/10/25 at 12:35 PM, LVN B stated she was responsible for monitoring and ensuring CNA A provided the proper level of care and assistance to Resident #1 on 11/01/25. LVN B stated she did this by walking the hall and looking for anything out of the ordinary and listening for anything regarding communication with the aides. LVN B stated she was not aware CNA A was providing the incorrect level of assistance, and assumed CNA A knew the level of care her residents required. LVN B stated she was not sure of changes in level of assistance being communicated. LVN B stated she would assume someone in administration would go and notify the staff. LVN B stated if residents were not provided with the proper level of assistance or care needed such as 2-person assistance it could cause injury. Attempted interview with CNA A via phone on 11/10/25 at 2:08 PM and 2:11 PM was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with the DON on 11/10/25 at 3:06 PM, she stated as per their facility policy CNA A had not followed the facility policy when she provided the incorrect level of assistance to Resident #1 for her transfer, bed mobility and incontinence care. The DON stated staff were checked for competency in following facility procedures such as verifying assistance levels upon hire and annually. The DON stated she did not have any written in services for CNA A that were prior to 11/01/25 and she provided CNA A with a verbal Inservice over verifying the levels of assistance in the Kardex/POC prior to working with residents but could not provide documentation. The DON stated she had not received any reports of CNA A not following facility procedures prior to 11/01/25. The DON stated 675672 Page 4 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 had no recent incidents, accidents, falls or altercations that could have caused the injury to her left leg. The DON stated when there were changes to residents' level of care or assistance it was communicated to staff either verbally by herself, or by therapy who would notify staff, by nurses on report or by checking the Kardex which would state what the resident's levels were. Record review of record of employee counseling provided by the DON to CNA A on 11/05/25 reflected the details of the situation as, failure to follow facility policy: POC and stated CNA A was educated on communication with nursing administration when unable to log in, how to use Kardex, and was given log in information. CNA A's level of counseling was marked as Suspension. Record review of CNA competency check list, dated 03/18/25 and completed by CNA A, had her categorized as Met for, Accessing the Kardex to review level of care & safety needs at beginning of shift and needed. The document did not include the signature of the nurse evaluator. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team with an updated date of 12/2024, did not include any verbiage regarding staff following the residents care plan. This was determined to be an Immediate Jeopardy (IJ) on 11/08/25 at 5:55PM. The Administrator was notified. The Administrator was provided with the IJ template on 11/08/25 at 5:55pm. The following Plan of Removal (POR) submitted by the facility was accepted on 11/08/25 at 10:12PM: [Facility]Date: 11/8/2025Plan of RemovalNotification:Date 11/08/25 time 5:55PM IJ template provided to entity: [Facility]. Facility ID - [ID#]. The notification of Immediate Jeopardy states as follows: The facility must ensure each resident receives adequate supervision and assistive devices to prevent accidents. CNA A CNA A failed to use 2 persons assist when transferring Resident #1 on 11/01/25, and when completing bed mobility during a brief change on 11/02/25. Corrective Action: 11/08/2025, the Administrator notified the Medical Director of immediate jeopardy. Ad hoc QAPI was conducted on 11/08/25 Resident #1 was discharged to the hospital 11/2/25. Education on Abuse and Neglect, as well as change of condition by Nursing on 11/2/25. CNA A suspended pending investigation on 11/5/25 11/08/2025, Nursing staff education initiated by DON on related to level of assistance needed with care and transfer, and where to locate the information of the level of care a resident needs. The facility DON / Designee will educate 100% of nursing staff prior to start of their shift on level of assistance with transfers and care the residents need to be provided. All new nursing hires will be educated on the Kardex, care plan that provide them the information on the level of care the resident needs by DON/designee. DON/designee to audit the Kardex / Care plan on every resident accuracy and that it includes level of care resident is to be provided, will be completed by nursing by 11pm 11/8/25. The initial self-report 11/2/25, intake number 1047302 was updated with addendum reflecting potential neglect on 11/08/25 by administrator. The DON will conduct random knowledge checks 3X week of nursing staff on location of level of care resident needs and where to locate information on Kardex starting 11/08/2025 and to continue for one month. Monitoring of the POR included the following: Observation on 11/09/25 at 7:33pm of 2 person hoyer transfer of Resident #7 completed by CNA Q and S revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #7's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Observation on 11/09/25 at 7:58pm of 2 person hoyer transfer of Resident #6 completed by CNA Q and S revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #6's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Observation on 11/09/25 at 8:11pm of 2 person hoyer transfer of Resident #4 completed by CNA S and LVN D 675672 Page 5 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #4's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Interviews on 11/09/25 and 11/10/25 included a total of 12 CNA's, including 5 aides from day shift, CNA J, K, L, M, P who worked 6:00am to 6:00pm and 7 night shift aides , CNA Q, R, S, T, U, V, W who worked from 6:00pm - 6:00am. Interviews also included 2 day shift medication aides, MA N and MA O who worked between 6:00am - 7:00pm, 4 LVNs who worked day shift from 6:00am-6:00pm including LVN C, X, Y, AB and 2 LVNs who worked night shift from 6:00pm -6:00am including LVN D and LVN AA. Interviewed included 2 RNs, RN Z and RN AC who worked from 6:00am to 6:00pm and 1 ADON and 1 DON who worked 8:00am-5:00pm. All staff interviewed stated they had recently received training since 11/02/25 when Resident #1 was identified with fractures to the left leg. Staff were trained over abuse and neglect and were aware of needing to report any abuse or neglect to the Administrator immediately. Staff were trained over where they could identify the residents level of assistance and stated they could find resident assistance levels, in the Kardex/POC/Care plan. Staff were trained on what to do when residents have any changes such a pain or skin changes and stated if they noted any changes in a residents condition such as pain or skin changes that aides would put an alert in their POC/Kardex and report to their nurse while nurses would complete a change in condition and make the appropriate notifications. Staff stated they were trained over what to do if they could not log in to their electronic charting software or POC and stated they would notify the ADON/DON. All staff interviewed were trained on how to access the Kardex and performed a return demonstration to the DON/ADON. The DON stated she would continue to monitor staff were aware of residents level of assistance/care and where to locate that information by doing random knowledge checks 3 times a week and developed a chart for tracking. The DON also stated all new staff would be trained over the same training they completed for their plan of removal, the DON also provided a chart she developed to monitor new staffs training. Record review of the AdHoc QAPI, dated 11/08/25, included the Medical director as an attendee and noted the Administrator notified the Medical Director of the immediate jeopardy. Record review of Resident #1's nursing notes and transfer form stated she was transferred to the hospital on [DATE]. Record review of record of employee counseling provided by the DON to CNA A on 11/05/25 reflected the details of the situation as, failure to follow facility policy: POC CNA A was educated on communication with nursing admin when unable to log in, how to use Kardex, and was given log in information. CNA A's level of counseling was marked as Suspension. Record review of a document provided by the DON used to mark off the Kardex and Care plan had been audited indicated all residents in the facility as of 11/08/25 had been checked off for both their Kardex and care plan. Record review completed on 11/10/25 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 accurately reflected residents level of assistance on their Kardex as it was indicated on their care plans. Resident #2's care plan and Kardex reflected 1 person assistance for transfers, toilet hygiene and 1 person assistance as needed for bed mobility. Resident #3's care plan and Kardex reflected 1 person assistance more assistance at times/as needed for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for toileting/incontinent care. Resident #4's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for toileting. Resident #5's care plan and Kardex reflected 1 person assistance with gait belt for transfers, and 1 person assistance for bed mobility and incontinent care. Resident #6's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for incontinent care. 675672 Page 6 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #7's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 2 person assistance as needed for bed mobility and 2 person assistance for toileting. Resident #8's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1-2 person assistance as needed for bed mobility and 1 -2 person assistance for incontinent care stating she may require more or less assistance due to decreased functional mobility and changes in cognition. Resident #9's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for incontinent care. Resident #10's care plan and Kardex reflected 1 person assistance with gait belt for transfers, and 1 person assistance for bed mobility and incontinent care. Resident #11's care plan and Kardex reflected 1 person assistance for transfers, and 1 person assistance for bed mobility as needed only and toileting/incontinent care. Record review of email provided by the Administrator indicated he submitted an addendum for his self-report related to Resident #1 that now included the allegation of neglect. Record review of in-services provided to staff indicated the following were provided:1. Abuse, neglect, exploitation, misappropriation prevention program - 11/02/252. Change in Residents condition or status (New/worsening pain, skin conditions, refusal of meds)- 11/02/253. POC: Kardex and transfers - Transfer status is verified and resident is to be transferred as per POC - How to access Kardex and how to input an alert - 11/07/254. [Electronic charting software]/POC: Kardex - when unable to login and access [Electronic charting software]/POC the DON/ADON need to be made aware to ensure that all nursing employees have access and are able to log in. - 11/08/255. POC: Kardex - How to access the Kardex and return demonstration - 11/08/25 The Administrator was informed the Immediate Jeopardy was removed on 11/10/25 at 3:48 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 675672 Page 7 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 3 residents (Resident #3) reviewed for medical records accuracy, in that: The facility failed to transcribe Resident #'3's paper care plan to her electronic care plan that was accessible by staff. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care, treatment and medication administration. The findings include: Record review of Resident #3's face sheet, dated 11/08/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: legal blindness, as defined in the USA (visual acuity of 20/220 or worse or field of vision 20 degrees or less), age-related physical debility, other osteoporosis (thin brittle bones) without currently pathological fracture, and repeated falls. Record review of Resident #3's Minimum Data Set assessment, dated 10/04/25, revealed Resident #3 had a BIMS score of 06, which indicated she was severely cognitively impaired. Record review of Resident #3's change in condition, completed by LVN C, reflected Resident #3 had a fall on the morning of 10/18/25 which resulted in a quarter size bump to head. Record review of Resident #3's care plan did not include any documentation related to falls that occurred on 10/18/25. Record review of Resident #3's care plan included a focus of I am at risk falls related to: stiffness of unspecified joint, repeated falls, age related physical debility. with a date initiation of 09/21/24. There was no verbiage related to Resident #3's fall on 10/18/25. During a record review and interview with MDS Nurse G on 11/07/25 at 4:00 PM, she stated on the day of Resident #3's fall on 10/18/25 their system was down so she used a paper care plan to document the fall and interventions, but stated she failed to upload it into Resident #3's chart and had the paper documents in her office. Record review of a paper document provided by MDS Nurse G was a copy of an admission checklist with Resident #3's name written on it along with Care Plan which stated, Focus, 10/20/25 risk for injuries/Fall. 10/18/25 - actual Fall.Goal 10/20/25 Injuries will resolve without complications through my review date.Interventions 10/20/25 Bed stand/furniture moved to prevent falls. During a record review and interview with the DON on 11/10/25 at 3:18 PM, he stated MDS Nurse G was responsible for completing the care plan for Resident #3 and items such as skin, activities of daily living and falls should be included in the care plan. The DON reviewed Resident #3's care plan in her electronic chart and stated she saw interventions but did not see her fall from 10/18/25. The DON stated Resident #3's fall was not on the care plan because they were in the process of switching from their old company to their new copy and the system was shut down so they did a paper care plan. The DON stated the information from the paper care plan should have been added to Resident #3's electronic chart. The DON stated it was important to include falls on the care plan so when someone checked the care plan, they would be aware of the residents' fall history. The DON stated MDS Nurse G monitored the care plans to ensure they had all required information and was not sure how often she did, but thought it was done quarterly. The DON stated MDS Nurse G was trained in developing the care plans and what should be included within the last 6 to 12 months. The DON stated she did not know exactly what the care plan stated in regard to including fall history. The DON stated she could not provide an answer on how not including a residents fall history on their care plan could negatively impact them but it was there to make other staff aware of their fall history. During an interview with MDS Nurse G on 11/10/25 at 3:52 PM, she stated she was responsible for completing the care plan for Resident #3. MDS Nurse G stated falls should be included on the residents care plans. MDS G 675672 Page 8 of 9 675672 11/10/2025 Avir at River Ridge 3922 W River Dr Corpus Christi, TX 78410

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #3's fall from 10/18/25 was not in the electronic system because their system was down at the time and she put it on paper and had not uploaded it. MDS Nurse G stated the information on Resident #3's paper care plan should have been added into her electronic chart. MDS Nurse G stated it was important to include falls on the care plan because if anything happened there would be a record you could go back to and see what incident happened and what the goals and interventions were. MDS Nurse G stated she reviewed and monitored the care plans to ensure they had all the required information. MDS Nurse G stated she monitored the care plans by running an order list in the morning to show any orders from the day before and by adding anything that was discussed in the morning meetings that needed to be added. MDS Nurse G stated she previously was trained on developing the care plan and what should be included, she stated she was trained on this when she first started through an MDS training, MDS Nurse G did not provide a date to this training. MDS Nurse G stated in regard to fall history on the care plan the facility policy stated to make sure it documented with the goals and intervention and whatever they were going to do to resolve the issue. MDS Nurse G stated in this situation she did follow the facility policy on paper but needed to uploaded it. MDS Nurse G stated not including a resident's fall history on their care plan could negatively impact them because people may not know if they were falling and it was a reference to look back on. During interview on 11/10/25 at 4:51 PM, the DON stated she did not have any documentation to provide for training of MDS Nurse G regarding development of care plans and what should be on it. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team, with an updated date of 12/2024, did not include any verbiage regarding what should be included on the care plan. 675672 Page 9 of 9