Health inspection·May 6, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #2 has a self-care deficit and required extensive assistance with bed mobility, bathing, hygiene, dressing and grooming related to weakness. Resident #2's transfer status required gait belt and assistance of one person and set-up assistance with meals. Review of the undated face sheet for Resident #3 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2, muscle weakness, cognitive communication deficit, constipation, altered mental status, depression, peripheral vascular disease (narrowing, blockage or spasms in a blood vessel), hypertension, and Alzheimer's disease. Review of the admission MDS assessment for Resident #3 dated 04/28/24 reflected a BIMS Score of 14 which reflected mildly impaired cognition, and use of a walker and a wheelchair. Resident #3 required partial to moderate assistance with bed mobility, bathing, hygiene, dressing and grooming. Review of the Care Plan for Resident #3 dated 5/06/24 reflected: Resident #3 was at risk for falls related to impaired mobility and to place call light/bell within easy reach and to respond promptly to calls for assist to the toilet. Observation on 5/06/24 at 1:00 PM revealed Resident #1's call light was on the floor by the head of the bed. Interview on 5/06/24 at 1:00 PM with Resident #1 revealed he had an issue with the call button not being answered and was having frequent diarrhea for the past two months following abdominal surgery. Resident #1 stated he would press the call button for help but nobody would come, or they would come in and tell him they would be right back and never come back. Resident #1 stated his wife could help him by picking up the call button when she was visiting, and if he was alone he would not be able to get help. Resident #1 stated he thought the facility was short staffed and had waited one hour for 4-5 times during past week to get cleaned up from having diarrhea. Observation on 5/06/24 at 1:14 PM of revealed Resident #2 was sitting up in wheelchair in her room with lunch tray on bedside table. Resident #2 stated she had no concerns with her care. Resident #2's call button was observed on the floor near the head of the bed. Resident #2 stated she was soon going to need to get up. Observation on 5/06/24 at 1:16 PM revealed CMA A had gone into Resident #2's room momentarily to check on her and then came out of the room and back to the med cart. Observation on 5/06/24 at 1:19 PM revealed Resident #2's call light remained on the floor in the same spot as first observation at 1:14 PM. Observation on 5/06/24 at 1:25 PM revealed Resident #3 sitting up in his wheelchair and his lunch tray on bedside table. Resident #3 stated he did not speak much English. Resident #3's call light was observed on the floor near the head of the bed. Interview on 5/06/24 at 2:02 PM with CMA A revealed she had worked at facility for five to six years. CMA A stated she will ask residents if they want their light left on or off, door opened or closed, and if they need anything else. CMA A stated, the call light is usually around the bed, and if it were on the ground, she would pick it up. CMA A further stated, I don't know why I did not pick up Resident #2's call light when I went into her room and we are supposed to make sure all residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 2 of 3 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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)

F 0558 have their call light nearby. Level of Harm - Minimal harm or potential for actual harm Interview on 5/06/24 at 2:05 PM with LVN A revealed she checked the overall condition of how a resident room looks, and for any equipment issues. LVN A stated she also looked at call lights, and the call light was usually pinned to bed or pinned to the resident. LVN A stated if the call light was found on the floor and someone goes in to help them, they should pick it up. Residents Affected - Some Interview on 5/06 24 at 3:22 PM with the DON revealed the importance of call light in reach when residents were going to bathroom, difficulty breathing, if they have fallen, or any type of need. The DON revealed his expectation was for all staff members to place all residents call light within reach while they are in bed, or up in chair. The DON further stated if the resident did not have their call light within reach, they could have a fall, have an emergency, need to go to the bathroom, or become soiled. Review of Policy and Procedure for Answering the Call Light dated October 2010 reflected, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident and to answer the resident's call as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 3 of 3