Inspection·December 31, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. NA A failed to have another staff assist while providing care for Resident #1 in the bed on 12/29/2024. Resident #1 rolled out of the bed, fell to the floor face down, was transferred to the ER and was diagnosed with laceration on left forehead, a subdural hematoma (collection of blood outside the brain that can be life threatening), a subarachnoid hemorrhage(bleeding in the space below the arachnoid layer of the brain) and possible C6/T1 fractures (C6 is the 6th cervical vertebrae that is in your neck, supports the head, protect the spinal cord and allow head motion; T1 is the 1st Thoracic vertebrae, connect the neck to the upper back) . Resident #1 was hospitalized . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/24 at 4:18 pm and an IJ template was given. While the IJ was removed on 12/31/24 at 1:47 pm, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for falls, injuries, hospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Vascular dementia, Cognitive communication deficit, Unspecified sequelae of cerebral infarction (a condition that may occur at any time after causal condition. Cerebral infraction is process that result in an area of necrotic tissue in the brain) . Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS( is a mandatory tool used to screen and identify the cognitive condition of residents) could not be conducted , and staff interview indicated Resident #1 had both short and long-term memory problems. Section GG (Functional abilities) reflected impairment on one side of both upper and lower extremities. It was also reflected in section GG Resident #1 was dependent to roll left and right - the ability to roll from lying on back to left and right side and return to lying on the back on the bed (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.). (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 7 Event ID: 676486 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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)