Health inspection·January 30, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews, observation and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, as identified in the comprehensive assessment, for 3 of 3 residents. reviewed for comprehensive care plans. The facility failed to adequately address fall/safety concerns specific for Residents #10. The facility failed to adequately address fall/safety concerns specific for Residents #12. The facility failed to adequately address fall/safety concerns specific for Residents #14. This failure could place residents of not receiving necessary care or proper care/treatment for falls.Findings included:Record review of Resident #10's Medical Diagnosis indicated a [AGE] year-old male admitted on [DATE], diagnoses included Alzheimer's disease with late onset, muscle weakness, and unsteadiness on feet. A record review of Resident #10's MDS assessment, completed on 11/11/2025, indicated Resident #10 had a BIMS score of 06, which indicated severely impaired cognition. The MDS indicated Resident #10 was at risk for falls.Record review of Resident #10's care plan with last revision date of 1/06/2026 indicated Resident #10 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. The care plan indicated Resident #10 used a mobility device and required assistance with transfers. Resident #10 was lacking the personnel center care for the falls the resident was having. Resident #10 had falls on 3-23-2024, 7-28-2024, and 1-13-2026. Record review of Resident #12's Medical Diagnosis indicated a [AGE] year-old female admitted on [DATE] and readmitted on [DATE], diagnoses included cellulitis of the abdominal wall (spreading bacterial infection), Alzheimer's disease with late onset, need for assistance with personal care, reduced mobility, and need for assistance with personal care.A record review of Resident #12's MDS assessment completed on 10/09/2025, indicated a BIMS score of 13, which indicated she was cognitively intact. A BIMS score of 13 indicates cognitive function is considered intact or within a normal range. Resident #12 was coded as a fall risk.Record review of Resident #12's care plan with last revision date of 1/06/2026, indicated Resident #12 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. The care plan indicated Resident #12 used a mobility device and required assistance with transfers. Resident #12 had 17 falls between 8-13-2025 and 12-27-2025. The care plan did not include a person-centered plan for Resident #12 to address falls.Record review of Resident #14's Medical Diagnosis indicated a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Sepsis (harmful microorganisms in the blood), repeated falls, obesity, and muscle weakness. A record review of Resident #14's MDS assessment, completed on 1/14/2026, revealed that Resident #14 had a BIMS score of 8, which indicated moderate cognitive impairment. Resident #14 was coded as a fall risk.Record review of Resident #14's care plan with last revision date of 1/06/2026, indicated Resident #14 was at risk for falls due to unsteady gait, decreased balance, Page 1 of 2 675948 675948 01/30/2026 Avir at Belton 810 E 13th Ave Belton, TX 76513

F 0656 Level of Harm - Minimal harm or potential for actual harm medications, and poor safety awareness. The care plan indicated Resident #14 used a mobility device and required assistance with transfers. The care plan showed that Resident #14 had 45 falls over the past 12 months. Residents Affected - Some 675948 Page 2 of 2