Health 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 Page 1 of 3 676301 676301 07/05/2025 Avir at Schertz 3301 Fm 3009 Schertz, TX 78154

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a gap greater than 2 1/3rd inches between rail and mattress, place pillows in gap to minimize risks. LN will review quarterly to minimize risks and ensure device is least restrictive. Left side of bed against wall, Fall Mat next to bed as tolerated. 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. Scoop Mattress as tolerated. Record review of Resident #3's Fall Risk assessment dated 6.26.25 reflected a high-risk score of 15 (high risk is greater than 10). Record review of a Nurse Note written by LPN B dated 4.13.25 at 5:40 AM revealed that Resident #3 had an unwitnessed fall without injury. Resident #3 was observed laying on a mat next to the bed. The resident was assessed, and vitals were taken with no remarkable findings. Resident #3 was dressed and taken to the Nurse's station for monitoring due to resident having dementia and not able to use call light system in place. Resident did not complain of pain. No new interventions noted after this fall. Record review of a Nurse Note dated 5.27.25 revealed that Resident #3 had an unwitnessed fall and was found laying [sic] on her left side on the floor mat next to the bed. The nurse note stated that the bed was in lowest position. Neuro checks completed. X-ray ordered for left shoulder. MD and RP notified. Given pain medication. No new interventions noted after this fall. Record review of a progress note dated 6.26.2025 at 10:30 PM revealed that Resident #3 had a fall resulting in a large hematoma to left forehead and a swollen left eye. The physician sent Resident #3 to the ER for evaluation and treatment. The facility added the interventions of the moving the bed against the wall and a using a floor mat after this fall. Observations of Resident #3's bed on 7.1.2025 at 12.49 revealed that the bed was turned so the left side was against the wall and a scoop mattress was not in use. During an observation and interview on 07.1.25 at 12:55 PM, Resident #3 was brought into her room in her wheelchair for the interview. Resident #3 was alert and oriented to person. A purple bruise was noted on left side of her face, and a large knot was observed above her left eye. Resident #3 was asked if she remembered what happened when she fell. She stated that she tried to get up and fell. Resident #3 did not remember the date and time and could not articulate why she got up. An interview with the DON on 7.3.2025 at 10:00 AM revealed that the facility had not used a scoop mattress for Resident #3 to her knowledge. She believed it was a restraint, so the facility decided against using it. She stated however that it remained on the care plan in case they decided to try it in the future. An interview on 7.5.2025 at 4:17 PM with the ADON revealed that the facility tried a scoop mattress a while back. The ADON added that the scoop mattress was discontinued because the resident stayed in one position and there was a concern with skin breakdown. It remained on the care plan in case of future use. 676301 Page 2 of 3 676301 07/05/2025 Avir at Schertz 3301 Fm 3009 Schertz, TX 78154

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a working call light for one (Resident #3) of ten residents reviewed for working call lights consistent with the residents needs as outlined in the care plan and facility policy for the Call System. The facility failed to ensure that Resident #3 had a functional call light to call for assistance as a fall risk intervention. 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 completed on 6.9.2025 revealed a BIMS score of 0 which indicated severely impaired cognition. Resident #3 was coded as dependent for transfer 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, dated 1.8.2025, reflected no intervention for a call system that the resident could use. Record review of Resident #3's Fall Risk assessment dated 6.26.25 reflected a high-risk score of 15 (high-risk is greater than 10). An observation on 07.1.25 at 12:49 PM, revealed that Resident #3 was not in the room. The DON tested the call light by pushing the button for Resident #3 at 12:55 PM and the light did not turn on at the room wall panel, in the hall above the door, or on the call light board at the nurse's station. Her roommate's (Resident #7's) call light was also tested and illuminated the wall panel, light outside the room, and nurses station light.During an interview on 07.1.25 at 12:49 PM, the DON confirmed Resident #3's light was not turning on at the room wall panel, in the hall above the door, or on the call light board at the nurse's station. She confirmed that the call light was not functioning. The DON stated it should function for the patient to be able to call for assistance. The DON stated that if the resident fell, they could not call for assistance. During an interview on 07.1.25 at 12:55 PM, the Administrator revealed that there was no work order for repair of the call light in Resident #3's room and the facility did not have a maintenance log for checking call light functionality. The Administrator stated that a maintenance staff member was not currently employed and that he, the Administrator, was responsible for maintenance requests. He stated that the call system was older requiring a reset sometimes which could require unplugging the light from the wall and plugging it back in or replacing the call system button device. During an observation on 7.1.2025 at 12:57 PM, the Administrator unplugged the call light button, re-plugged, and this investigator confirmed that it was again functional. Record review of the facility's policy on call systems states Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 3. The resident call system remains functional at all times. If visual communication is used, the lights remain functional. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. 5. The resident call system is routinely maintained and tested by the maintenance department. Residents Affected - Few 676301 Page 3 of 3