Inspection·July 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #3) of six residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to meet Resident #3's fall risk needs. The care plan listed interventions that were not in use and interventions that were in use but not listed on the care plan/Kardex. This failure could place the residents at risk of not receiving necessary care and services.Findings include: Record review of Resident #3's Face Sheet, dated 07.1.2025, reflected an [AGE] year-old female who was readmitted to the facility on 08.25.2025 with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle wasting and atrophy, muscle weakness (generalized), and difficulty in walking. Record review of Resident #3's MDS assessment completed on 6.9.2025 revealed a BIMS score of 0 which indicated severely impaired cognition. Resident #3 was coded as dependent for transfers and needing substantial/maximal assistance to roll left/right or move from sitting to lying. Resident #3 was coded as independent when moving from lying to sitting on the side of the bed and as using a manual wheelchair to ambulate. Resident #3 was coded as having falls since Admission/Entry. Record review of Resident #3's Comprehensive Care Plan with an approach start date of 9.9.2024 from the legacy EMR reflected she has experienced a fall with an X next to confusion. The interventions listed in the care plan include a call bell in reach, explain/encourage use and answer promptly, needs anticipated and provide needed equipment, bolster mattress. Interviews with the DON, LVN C, and CNA D revealed that Resident #3 could not use the call light. The DON revealed that a bolster mattress had not been tried to her knowledge. Record review of Resident #3's Comprehensive Care Plan dated 4.4.2025 from the current EMR reflected she was at risk for falls and had a fall with the latest interventions dated 06.26.25 to place the resident's bed in the lowest position and the use of a fall mat. Prior to 6.26.2025, the Care Plan listed, Remind me to use assistive devices and to use call device (pull cord, call light) for assistance as needed. Remind me to use call device (pull cord, call light) for assistance as needed. and Scoop Mattress as tolerated. Interviews with the DON, LVN C, and CNA D revealed that Resident #3 could not use the call light. The DON revealed that a scoop mattress had not been tried to her knowledge. Record review of Resident #3s Kardex (POC) dated as of 7.3.2025, stated: Ensure | am wearing appropriate-fitting clothing and footwear (non-skid socks or shoes) that fits well when ambulating or mobilizing in w/c. | will be using bilateral assistive bars for increased independence with bed mobility and transfers. Side Rails do pose a risk of entrapment. Staff should ensure side rails are securely fastened to bed frame and do not swivel/slide. If rails have (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: 676301 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 676301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Schertz 3301 Fm 3009 Schertz, TX 78154 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)