Health inspection·April 18, 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 comprehensive person-centered care plan for 1 of 5 Residents (Resident #1) whose records were reviewed, in that: Resident #1's Care Plan still reflected resident was a 1 person transfer when she was a 2-person transfer. The deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: Record review of Resident #1's face sheet, accessed [DATE], reflected an [AGE] year-old female admitted [DATE] and expired [DATE], with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), cerebral infarction (necrotic tissue in the brain), and dementia (group of symptoms affecting memory, thinking and social abilities). Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected Resident #1 was substantial/maximal assistance (helper does MORE THAN HALF the effort) for chair/bed-to-chair transfers and had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's care plan, last reviewed [DATE], reflected ADLs functional status/rehabilitation potential with intervention Ambulation/Transfers amount of assist:1 person, dated [DATE]. It further reflected The following tasks will be documented in POC CareAssist with intervention 2 person assist with transfers, dated [DATE]. Interview on [DATE] at 04:49PM, CNA A had been working at the facility since October or [DATE]. He revealed Resident #1 was transferred with a mechanical lift. He revealed there was a cheat sheet that told the nursing staff how residents were transferred to include 1 person, 2 person, or mechanical lift. He revealed it was important to know how to care for residents so he could help them out more. Interview on [DATE] at 12:30PM, LVN B revealed Resident #1 was transferred with a mechanical lift and 2 people were needed for this transfer. She revealed she did not read care plans and the information about resident care was reported verbally amongst nursing staff. She revealed she would let the DON know to update care plan when a resident needed something different like transfers. She further revealed it was important to update care plans for resident care. She revealed if the nursing staff Page 1 of 5 675871 675871 04/18/2025 Avir at Comfort 615 Faltin Ave Comfort, TX 78013

F 0656 did not know what to do for a resident, then they would refer to the care plan to figure it out. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 01:03PM, LVN C revealed Resident #1 was transferred via mechanical lift most of the time. She revealed 2 people were needed for a mechanical lift. She revealed the nursing staff relayed information about resident care via word of mouth. Residents Affected - Few Interview on [DATE] at 11:00AM, CNA D revealed Resident #1 was a 2-person mechanical transfer. She revealed she read the residents' care plans to know how to care for the residents. Interview on [DATE] at 02:16PM, the DON reviewed the care plan screen and that it reflected a 1-person transfer for Resident #1, which needed to be updated so the resident was not inappropriately transferred since Resident #1 was a mechanical lift that required a 2 person transfer The DON further revealed she oversaw that care plans were updated as needed. Record Review of the facility policy, revised [DATE], Care Plans, Comprehensive Person-Centered, reflected, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 675871 Page 2 of 5 675871 04/18/2025 Avir at Comfort 615 Faltin Ave Comfort, TX 78013

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide nursing care with a sufficient number of nursing personnel on a 24-hour basis to all residents in accordance with resident care plans for 1 out of 4 days (04/07/25) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care for approximately 5 hours during the 2P-10P shift on 04/07/25. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing. Findings include: Record review of Resident #2's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities), unsteadiness of feet, and generalized muscle weakness. Record review of Resident #2's quarterly MDS assessment, dated 04/05/25, reflected Resident #2 was partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfers and had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #2's care plan, last reviewed 03/24/25, reflected I have a history of fall R/T impaired mobility and impaired balance with intervention resident is educated to wait for staff to supervise with transfers., dated 03/31/25. Record review of Resident #3's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include insomnia, dementia (group of symptoms affecting memory, thinking and social abilities), lack of coordination, major depressive disorder, and need for assistance with personal care. Record review of Resident #3's annual MDS assessment, dated 01/16/25, reflected Resident #3 was substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and was dependent (Helper does ALL of the effort) to wheel her wheelchair 50 feet with two turns and wheel 150 feet. It further revealed Resident #3 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last reviewed 03/24/25, reflected [Resident #3] is at risk for disturbed sleep patter R/T insomnia with intervention Encourage resident to go to bed at the same time everyday and wake up at the same time everyday., dated 03/27/24. Record review of Resident #4's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include age-related physical debility, lack of coordination, muscle weakness, and need for assistance with personal care. Record review of Resident #4's quarterly MDS assessment, dated 02/07/25, reflected Resident #4 was 675871 Page 3 of 5 675871 04/18/2025 Avir at Comfort 615 Faltin Ave Comfort, TX 78013

F 0725 had a BIMS score of 15 out of 15, indicating intact cognition. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #5's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include cerebral palsy (group of permanent neurological disorders that affect body movement and muscle coordination), need for assistance with personal care, moderate intellectual disabilities, and depression. Residents Affected - Many Record review of Resident #5's quarterly MDS assessment, dated 01/24/25, reflected Resident #5 had a BIMS score of 02 out of 15, indicating severely impaired cognition. It reflected Resident #5 had frequent urinary incontinence and frequent bowel incontinence and needed substantial/maximal assistance (helper does MORE THAN HALF the effort) to roll left and right. Record review of Resident #5's care plan, last reviewed 03/24/25, reflected Urinary Incontinent Care with an intervention To assess resident incontinence and protect skin integrity, dated 03/31/25. Interview on 04/16/25 at 09:50AM, Resident #2 revealed last Monday, 04/07/25, there were no CNAs after a certain time on the 2PM-10PM shift. She revealed her call light was not answered when she wanted to transfer herself from her wheelchair to bed. (Resident #2 was unable to recall any specific times related to using her call light and transferring herself.) She revealed she transferred herself without falling. She revealed her roommate Resident #3 went to bed around 11PM on 04/07/25, when Resident #3 typically went to bed around 7PM. Interview on 04/16/25 at 04:23PM, CNA A revealed last Monday 04/07/25 he knew from Resident #2 about CNAs not being in the facility. He stated the Staffing Coordinator said there were no CNAs scheduled from 2PM-10PM. He stated that was not typical for the facility. Interview on 04/16/25 at 05:19PM, LVN F revealed he worked Monday 04/07/25 2PM-10PM. He further revealed they were without a CNA from 5PM-10PM. He revealed the nurses did everything to include passing out medications, wound care, feeding, and answering call lights. He revealed there was nothing he knew of that was missed, but that some residents went to bed later than planned. Interview on 04/16/25 at 06:33PM, the DON revealed on Monday 04/07/25 CNA A was at the facility until about 5:30PM. She revealed Nurse Aide E was originally on the schedule to cover 5PM-10PM time frame but had left at 5PM instead. The DON revealed she was switching to 12-hour shifts, so she could have a pool of nursing staff she could call in to work if that happened again. She revealed to make sure resident care was not missed on this evening, the nursing staff talked about grievances in the morning huddle, and she went into everyone's rooms to make sure residents were fine. She revealed she found there was no effect on resident care at that time. Interview on 04/18/25 at 11:40AM, the DON revealed it was important to make sure there were CNAs scheduled throughout the day. She revealed she scheduled 2 CNAs for the 2PM-10PM shift and at least 3 for the 6AM-2PM shift. She further revealed it was important to have enough CNAs so there was not a delay in care and so this did not affect nursing duties like medication pass when the nurses may need to help CNAs or do CNA work instead. Interview on 04/18/25 at 12:50PM, Nurse Aide E revealed she was not aware that she was scheduled to work on 04/07/25 on the 2P-10P shift. She revealed she left the facility at 5PM. Interview on 04/18/25 at 05:40PM, Resident #3 revealed she typically went to bed at 7PM but she was 675871 Page 4 of 5 675871 04/18/2025 Avir at Comfort 615 Faltin Ave Comfort, TX 78013

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many put to bed at 10P or 11P on 04/07/25. She revealed she preferred going to bed at 7PM after she took her medications because they made her drowsy. Interview on 04/18/25 at 05:43PM, Resident #4 revealed the call lights were not being answered on 04/07/25 evening. She revealed her roommate, Resident #5 had her call light on but was never responded to. Resident #4 revealed she had to change Resident #5's brief because she was wet. Resident #5 was present during this interview and unable to be interviewed. Record review of the Facility Assessment Tool reflected the total minimum number needed or average or range of nurse aides were 2 on afternoon shift. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide E clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide H clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide I clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide J clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA A clocked out at 5:06PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA G clocked in at 10:07PM on 04/07/25. Record review of facility's policy Staffing, revised July 2021, reflected Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment . 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 675871 Page 5 of 5