Health inspection·August 22, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 observation, 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 #3) reviewed for quality of care. CNA A transferred Resident #3 using a mechanical lift without the assistance of another staff member. This failure could place residents at risk of accidents, injury, and pain. The findings were: Record review of Resident #3's face sheet dated 8/22/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included Wernicke's encephalopathy (an acute, life-threatening neurological emergency caused by a severe thiamine (Vitamin B1) deficiency, most often due to chronic alcohol abuse but also associated with poor nutrition or malabsorption. Its classic symptoms include loss of muscle coordination), generalized muscle weakness, muscle wasting and atrophy not elsewhere classified unspecified site (wasting or loss of muscle tissue), and Transient Ischemic Attack (TIA - short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain). Record review of Resident #3's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 out of 15 indicating the resident was cognitively intact, used a wheelchair, and required extensive assistance of a 2- person physical assist for bed mobility, and transfers. Record review of Resident #3's undated care plan revealed a problem with a start date of 6/6/25 edited on 6/17/25 for ADL function that the resident required a mechanical lift, with a goal of safe travels and an approach to maintain safe transfers. In an observation and interview on 8/21/25 at 10:04 a.m. CNA A opened the door to Resident #3's room and exited the room pushing the mechanical lift out in to the hallway. Resident #3 was in his wheelchair in his room with the mechanical lift sling underneath him. There were no other staff members in Resident #3's room. CNA A stated no one had helped her transfer the resident. CNA A stated she transferred Resident #3 from his bed to his wheelchair alone with the mechanical lift. CNA A stated she was not supposed to transfer the residents with the mechanical lift alone. CNA A stated she did not ask anyone for assistance with the mechanical lift as when she looked down the hall, she did not see anyone and went ahead and transferred the resident without the assistance of another staff member. In an observation and interview on 8/21/25 at 10:08 a.m. Resident #3 was sitting in his room in his wheelchair with the mechanical lift sling underneath him. Resident #3 stated CNA A had transferred him using the mechanical lift by herself without the assistance of another staff member and stated there were no issues with the transfer and he felt safe during the transfer. Resident #3 stated the facility staff including CNA A did not usually use the mechanical lift to transfer him without the assistance of another staff member but he had wanted to get up. In an observation on 8/21/25 at 10:10 a.m. the DON was in-servicing staff on 2-person transfers using mechanical lifts. In an interview on 8/22/25 at 12:00 p.m. the DON stated it was important to use 2-persons for a mechanical lift to ensure control of the mechanical lift, ensure the resident was (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 3 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 08/22/2025 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)