Health inspection·February 4, 2026

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, failed to review the risks and benefits of bed rails, and failed to check bed rails regularly to make sure they are still installed correctly with 1 (Resident #1) of 4 residents reviewed for the use of bed rails. Resident #1 used one-quarter bed rails bilaterally for increasing bed mobility. However, the facility did not conduct safety assessments for bed rails quarterly per the facility care plan, and the bed rails were installed incorrectly as evidence by not lowering the bed rails because the bed rails were jammed. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.Findings included: Record review of Resident #1's face sheet, dated 02/03/2026, revealed she was an [AGE] year-old female, originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of hypertensive heart disease (condition with damage to the heart because of high blood pressure), obesity (complex disease involving having too much body fat), and muscle wasting and atrophy (breakdown of muscles). Further record review of the resident's face sheet revealed the resident was discharged to an acute hospital on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated 01/15/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact. The resident had no impairment to upper and lower extremities regarding functional limitation in range of motion, and the resident was dependent (helper does all of the effort) for chair to bed and toilet transfers. Record review of Resident #1's comprehensive care plan, dated 05/05/2025, revealed the resident needed to have mechanical transfers with two persons , and using bilateral 1/4 rails for increased independence with bed mobility. For the intervention, Staff should ensure side rails are securely fastened to bed frame and do not swivel/slide. If rails have a gap greater than 2 1/3rd inches between rail and mattress, place pillows in gap to minimize risks. Nurses will review quarterly to minimize risks and ensure device is least restrictive. Record review of Resident #1's physician order, dated 10/20/2025, revealed the resident had the order of May use 1/4 rails to bed bilaterally for bed mobility and positioning. Record review of Resident #1's Bed Rail Assessment, dated 05/05/2025, revealed that the resident could use her bed rails safely as evidence by Side Rails/Assist Bar are indicated and serve as an enabler to promote independence. Further record review of the resident's bed rail assessments revealed there were no more bed rail assessments to September (2nd quarter) and December (3rd quarter), 2025. Observation on 02/03/2026 at 2:30 p.m. revealed Resident #1's bed had one-quarter bed rails bilaterally, and the bed rails were up. CNA-A tried to lower the bed rails but could not because the both bed rails were jammed. During an interview on 02/03/2026 at 2:30 p.m., CNA-A stated Resident #1 was in an acute hospital (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: 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 02/04/2026 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)