Health inspection·July 10, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #13) who were observed for call light placement. Residents Affected - Few The facility failed to ensure the call light was within reach for Resident #13. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #13's face sheet, dated 07/10/2024, revealed she was admitted to the facility on [DATE] with diagnoses which included: other specified chronic obstructive pulmonary disease, essential hypertension, dementia in other diseases classified elsewhere, unspecified severity, with anxiety, unspecified macular degeneration, shortness of breath, and localized edema. Record review of Resident #13's admission MDS assessment, dated 06/29/2024, revealed the resident's BIMS score was 12, which indicated moderate cognitive impairment. The admission MDS assessment further revealed Resident #13 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfer, dependent (helper does all the effort) for upper body dressing and partial/moderate assistance (helper does less than half the effort) for personal hygiene. Record review of Resident #13's care plan, revision date of 07/02/2024, revealed Resident #13 had a problem of Category: Falls. Falls/Safety/Elopement Risk and approach revealed Encourage use of call light. Keep call light within reach. Observation and interview on 07/07/2024 at 10:35 a.m. revealed Resident #13's call light on the floor at the foot of the bed near privacy curtain with Resident #13 at bedside sitting in her wheelchair. Resident #13 stated she wished she could get someone who could help her turn her light on. Resident #13 stated she did not know where her call light was, but she only knew of the string to her light over her bed. During an interview and observation on 07/07/2024 at 10:42 a.m. LVN B revealed Resident #13 did not have her call light within reach and would need to get a stuffed animal on it because they usually have one on them as she placed the call light from the floor to the bed. LVN B stated Resident #13 would not have been able to reach the call light. Resident #13 took the string in her hand. LVN B further stated everyone was responsible to place the call light within reach. (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 7 Event ID: 675871 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 675871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Comfort 615 Faltin Ave Comfort, TX 78013 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)