Health 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 Page 1 of 2 676114 676114 09/16/2025 River Hills Health and Rehabilitation Center 2091 Bandera Hwy Kerrville, TX 78028

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few score of 12, indicating moderately impaired cognition. Section J1900 of the MDS reflected Resident #2 had experienced 2 falls without injury during the assessment period. Record review of a documented Fall Risk Evaluation of Resident #2 dated 7/29/2025 reflected a score of 16.0 and categorized the resident as at risk. Record review of Resident #2's comprehensive care plan, accessed and printed on 9/16/2025, reflected care planning for physical/verbal aggression, actual falls related to poor balance/poor communication and comprehensive/ poor safety awareness/ unsteady gait, and risk for falls. Interventions for actual falls included a fall mat (initiated 3/26/2026) and a scoop mattress (a modified bed mattress with defined edges to prevent someone from rolling out of bed) (initiated 5/08/2025). Record review of the facility's incident and accidents report dated 9/16/2025 reflected the most recent fall by Resident #2 was on 7/29/2025. In an observation and interview on 9/16/2025 at 1:44 PM, Resident #2 was observed awake and resting in bed. Resident #2's fall mat was folded up and leaning against furniture in the room. Resident #2 was unable to participate in the attempted interview due to cognitive decline. A subsequent observation on 9/16/2025 at 2:10 PM revealed the fall mat had not been implemented and remained leaned against the furniture. In an interview with CNA B on 9/16/2025 at 1:46 PM, she stated Resident #1 and #2 care plan interventions included lowering the bed and implementing a fall mat whenever they were in bed. She was unaware Resident #2's fall mat was not implemented at that time, and she stated Resident #2 had recently returned from physical therapy. She theorized the physical therapy staff likely did not replace the fall mat after assisting Resident #2 into bed. She stated Resident #1 had the fall mat in place earlier in the day and had probably been moved by HCNA C while she was providing care. CNA B stated the possible harm to residents from not having care planned fall mats in place was fall with injury. In an interview with LVN A on 9/16/2025 at 1:51 PM, she reported Residents #1 and #2 both require fall mats for fall prevention. she stated Resident #2 was brought to the nurse's station after the therapy session earlier that day, not to his room. She stated Resident #2 was then assisted to his room and into bed by a CNA. She was not aware that the fall mat was not implemented at that time. LVN A stated the fall mat for Resident #1 was implemented earlier in the day, and she was unaware HCNA C had not implemented the fall mat after providing care. She stated she rounded on all residents at least hourly to ensure fall prevention measures were in place. LVN A stated the potential harm to residents from not having care planned fall mats implemented was serious injury. In an interview with the DON on 9/16/2025 at 3:00 PM, she reported Residents #1 and #2 both had fall prevention care planning that included fall mats. She stated staff had made aware of the surveyor observation of Resident #2's fall mat not in place. She stated she spoke with CNA B, LVN A, and the physical therapy department regarding the fall mat, and she attributed the implementation failure to a temporary, agency staff member that she had terminated earlier in the day due to performance issues. The DON stated her expectation was that all staff, including facility employees, hospice, and agency, would implement care planned fall prevention measures at all times. She stated she ensured that any staff providing care for residents were given access to the electronic medical record system, including the Cardex which provided a synopsis of required interventions, including fall mats.Record review of the facility policy titled Accidents (undated, printed 9/16/2025) reflected the following:Individualized, person-centered interventions will be implemented, including adequate supervision and assistive devices, to reduce risks related to hazards in the environment. 676114 Page 2 of 2