Inspection·September 16, 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 receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and #2) reviewed for accidents/hazards. The facility failed to ensure fall mats were in place while Residents #1 and #2 were in bed on 9/16/2025. These failures could result in injury to residents. Findings included:Resident #1:Record review of Resident #1's face sheet, dated 9/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included displaced intertrochanteric fracture of the right femur (a break in the large, upper bone of the right leg), fracture of the superior rim of right pubis (a break of a bone in the pelvis), vascular dementia (a progressive disorder causing cognitive decline), and repeated falls. Record review of Resident #1's quarterly MDS, submitted 8/26/2025, reflected a BIMS score of 05, indicating severely impaired cognition. Section J1900 of the MDS reflected Resident #1 had experienced 1 fall without injury during the assessment period.Record review of a documented Fall Risk Evaluation of Resident #1 dated 9/11/2025 reflected a score of 19.0 and categorized the resident as at risk. Record review of Resident #1's comprehensive care plan, accessed and printed on 9/16/2025, reflected care planning for fall prevention, actual falls, and behavior problems related to poor safety awareness. Interventions for actual falls included a fall mat (initiated 8/08/2025) and relocation to a room closer to the nurse's station (initiated 6/17/2025). Record review of the facility's incident and accidents report dated 9/16/2025 reflected the most recent fall by Resident #1 was on 9/11/2025.In an observation and interview on 9/16/2025 at 1:45 PM, Resident #1 was observed awake and resting in bed. The fall mat was folded up and leaning against furniture in the room. HCNA C was exiting Resident #1's room and stated she had just completed routine hygiene tasks for Resident #1 and was finished providing care. After exiting the room, HCNA C did not return to implement the fall mat. Resident #1 was unable to participate in the attempted interview due to cognitive decline. A subsequent observation of Resident #1 on 9/16/2025 at 1:55 PM revealed the fall mat had not been implemented and remained leaned against the furniture. In an interview with HCNA C on 9/16/2025 at 1:57 PM, she reported she was not aware Resident #1 required a fall mat for fall prevention as the fall mat was not in place when she entered his room to provide care. She stated she saw the fall mat leaning against the furniture but was unsure if the fall mat belonged to Resident #1 or his roommate. HCNA C stated she was provided the information about fall prevention measures for residents from the facility nursing staff or through the medical chart. She reported potential harm to residents from not having a care planned fall mat implemented was serious injury or death. Resident #2: Record review of Resident #2's face sheet, dated 9/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Parkinsonism (a progressive, degenerative neurological disorder causing tremors and muscular weakness) and repeated falls. Record review of Resident #2's quarterly MDS, submitted 8/13/2025, reflected a BIMS (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 2 Event ID: 676114 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 676114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Hills Health and Rehabilitation Center 2091 Bandera Hwy Kerrville, TX 78028 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)