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 interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents hazards and supervision, in that: The facility failed to ensure on 10/16/2025 Resident #1 was transferred by CNA A and RN A using standing pivot transfer x 2 staff without a gait belt. During transfer Resident #1 became too heavy for CNA A and RN A and Resident # 1 was lowered to the floor causing Resident # 1 knees to be in a bent position while sitting on the floor. Resident #1 was sent to the hospital and diagnosed with a displaced periprosthetic distal Femoral fracture (broken thigh bone near a hip implant that has shifted out of position) The non-compliance was identified as past noncompliance (PNC). The noncompliance began on 10/16/25 and ended on 10/27/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of falls with injuries. Findings include: Record review of Resident # 1's face sheet revealed a 91-year -old female admitted to the facility on [DATE] with readmission on [DATE]. Her diagnoses include Muscle Weakness (Generalized) (a lack of muscle strength or the inability to control voluntary muscle force), Lack of Coordination (condition that affects the ability to control and execute smooth, and precise movements), restless leg syndrome (disorder characterized by irresistible urge to move the legs), acute respiratory failure and mild cognitive impairment. Record review of Resident # 1's change of condition MDS assessment dated [DATE], reflected a BIMS of 11(moderate cognitive impairment). Section GG reflected Resident #1 required partial/moderate assistance with transfers. Record review of Resident #1's Care Plan dated 7/28/2025 reflected Resident #1 required staff assistance with transfers and staff to provide assistance using a gait belt, if physical assistance needed for transfers. Resident#1 was at risk for falls due to unsteady gait, lack of coordination, CVA, mood decline, restless leg syndrome, muscle weakness, altered respiratory status, decreased balance, medications, and poor safety awareness. Record review of Resident #1's Kardex on 10/28/2025 reflected Resident #1 required 2-person physical assistance using gait belt for transfers. Record review on 10/28/2025 of the administrator's investigation report (not dated) reflected on 10/16/2025 around 8:30PM RN A and CNA A assisted Resident #1 to the floor while attempting to transfer Resident #1 from bed to wheelchair. RN A noted Resident #1 knees were in a bend position while sitting on the floor and CNA A held her up while RN A went to get assistance from CNA B because the resident was too heavy for a 2-person transfer. CNA B stated he assisted RN A and CNA A in transferring Resident #1 from the floor into the wheelchair. CNA A and CNA B stated Resident #1 did not scream in pain. After the accident Resident #1 complained of knee pain and stated, knees are broken, and she can never walk around again due to her being placed on the ground. Record review of medication administration revealed Resident #1 was given Hydrocodone-Acetaminophen 7.5-325 mg tablet on 10/16/2025 for complaint of generalized pain of 7 out of 10. Record review of nurse note dated 10/17/2025 at 1:15PM from RN A revealed Page 1 of 3 675948 675948 11/10/2025 Avir at Belton 810 E 13th Ave Belton, TX 76513

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she called Resident #1's hospice care team to request an x-ray which was denied but stated they would notify her case manager. Nurse A notified the on-call physician and obtained an order for stat x-ray, which was done onsite at the facility. Nurse A contacted Resident #1's responsible party to inform them of the incident and the party responsible requested Resident #1 be sent to the Hospital Record review of the radiology report dated 10/17/2025 on 3:53AM confirmed the right knee had a displaced periprosthetic distal femoral fracture. Record review of hospital records revealed, Resident # 1 was admitted on [DATE] with displaced right periprosthetic distal femoral fracture. On 10/18/2025 Resident #1 received Intramedullary rod to right femur. Resident #1 was discharged home on [DATE]. Record review of CNA A's interview with the ADON and DON dated 10/17/2025 revealed CNA A and Nurse A each lifted Resident #1 under each arm to transfer Resident #1 from the bed to her wheelchair and then when they were unable to transfer Resident #1 they sat her back on the bed to regroup and try again. They again tried to transfer Resident #1 by standing her up and holding her brief with one hand and another arm under her arm. They were unable to turn her safely, so they sat her gently on the floor. In an interview with CNA B on 10/28/2025 at 12:11 PM, he stated that he walked into Resident #1's room to assist RN A and CNA A with transferring Resident #1 from the floor to the wheelchair. He and CNA A each lifted Resident #1 under the arm and RN A lifted her legs. They placed Resident #1 in the wheelchair, and she did not complain of pain at that time. He stated they did not use a gait belt. He stated that's where we messed up. We should have used a gait belt for her (Resident #1) transfer. He stated that it was documented in Resident #1 Kardex and care plan to use a gait belt for transfers, and they did not follow it. He stated that the gait belt is used to help transfer the resident safely. He stated after the incident he received in service training over abuse, neglect, identifying types of abuse and safe lifting and movement of residents. In an interview with CNA A on 10/28/2025 at 6:31 AM, she stated that her and RN A attempted to transfer Resident #1 from the bed to the wheelchair that resulted in placing Resident #1 on the floor. RN A requested additional help from CNA B to help transfer Resident #1 from the floor into the wheelchair. CNA A, RN A, and CNA B together transferred Resident #1 from the floor into the wheelchair. She denied using a gait belt for Resident #1's transfers. She stated after the incident she received a one-on-one in-service training on abuse, neglect, identifying types of abuse, and safe lifting and movements of residents. She stated that a gait belt is used to transfer residents safely and prevent falls. In an interview with the RNC on 10/28/2025 at 7:34 AM, she stated the staff should have used a gait belt during the transfer on 10/16/2025 with Resident #1. All staff have since received in-servicing over proper transfers, gait belt use, abuse, neglect, and using the Kardex to find residents transfer status. After the investigation was completed, an Ad Hoc QAPI Committee was convened, a Root Cause Analysis was completed. In an interview with RN A on 10/28/2025 at 1:15 PM, she stated her and CNA A attempted to transfer Resident #1 from the bed to wheelchair that resulted in slowly lowering Resident #1 to the ground due to Resident # 1 being too heavy to transfer. She denied using a gait belt for the transfer. She stated they did not use a gait belt to transfer Resident #1 because they did not need it due to them doing a lift and turn transfer. They would use a gait belt for the resident if she was walking a distance. She stated that she had been trained on abuse, neglect, and resident transfers during time of hire, but did not receive training on resident transfers after the incident because she resigned from the facility after the incident. Record review of facility policy undated titled Safe Lifting and Movement of Residents policy statement reads, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Record review of the facility in-service one on one training titled Abuse, 675948 Page 2 of 3 675948 11/10/2025 Avir at Belton 810 E 13th Ave Belton, TX 76513

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few neglect, identifying typed of abuse, safe lifting and movement of residents and dated 10/27/2025 reflected the signature of CNA A. Record review of facility staff in-services titled Safe lifting and movement of residents, abuse, neglect, exploitation and misappropriation prevent program and dated 10/17/2025 reflected the signatures of CNA B, Record review of facility in-service titled Abuse, neglect policy dated 10/20/2025 reflected the signatures of the DON, ADON, and administrator. The facility implemented interventions prior to the entrance of the investigation on 10/28/2025 to correct the non-compliance. Confirmed through a record review of the facility Investigation Report and confirmed during an interview with RNC, in-service training was implemented with all direct care staff on Safe Lifting and Movement of Residents and Abuse, Neglect. One on one training was conducted for CNA A over safe lifting and movement of residents policy. RN A after the incident. Other corrective actions included the implementation of the QAPI Ad Hoc Committee that included Root cause and corrected actions. Root cause indicated two staff members lacked knowledge of proper transfer techniques involving the use of a gait belt which contributed to an assisted fall. Corrected Actions included Interview with all staff involved to determine the root cause of the assisted fall. Inservice: Abuse/Neglect, Proper Transfer and Use of Gait belts, Assessment for suspected fracture, and how to find transfer status in PCC. Each team member is to be issued a gait belt and instructed on it's proper use. Care plan audit to ensure transfer status is accurate for all residents. Skills check- off for transfers for all direct care staff. 675948 Page 3 of 3