River Hills Health And Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
score of 12, indicating moderately impaired cognition. Section J1900 of the MDS reflected Resident #2 had experienced 2 falls without injury during the assessment period. Record review of a documented Fall Risk Evaluation of Resident #2 dated 7/29/2025 reflected a score of 16.0 and categorized the resident as at risk.
Record review of Resident #2's comprehensive care plan, accessed and printed on 9/16/2025, reflected care planning for physical/verbal aggression, actual falls related to poor balance/poor communication and comprehensive/ poor safety awareness/ unsteady gait, and risk for falls. Interventions for actual falls included a fall mat (initiated 3/26/2026) and a scoop mattress (a modified bed mattress with defined edges to prevent someone from rolling out of bed) (initiated 5/08/2025). Record review of the facility's incident and accidents report dated 9/16/2025 reflected the most recent fall by Resident #2 was on 7/29/2025. In an
observation and interview on 9/16/2025 at 1:44 PM, Resident #2 was observed awake and resting in bed.
Resident #2's fall mat was folded up and leaning against furniture in the room. Resident #2 was unable to participate in the attempted interview due to cognitive decline. A subsequent observation on 9/16/2025 at 2:10 PM revealed the fall mat had not been implemented and remained leaned against the furniture. In an
interview with CNA B on 9/16/2025 at 1:46 PM, she stated Resident #1 and #2 care plan interventions included lowering the bed and implementing a fall mat whenever they were in bed. She was unaware Resident #2's fall mat was not implemented at that time, and she stated Resident #2 had recently returned from physical therapy. She theorized the physical therapy staff likely did not replace the fall mat after assisting Resident #2 into bed. She stated Resident #1 had the fall mat in place earlier in the day and had probably been moved by HCNA C while she was providing care. CNA B stated the possible harm to residents from not having care planned fall mats in place was fall with injury. In an interview with LVN A on 9/16/2025 at 1:51 PM, she reported Residents #1 and #2 both require fall mats for fall prevention. she stated Resident #2 was brought to the nurse's station after the therapy session earlier that day, not to his room. She stated Resident #2 was then assisted to his room and into bed by a CNA. She was not aware that the fall mat was not implemented at that time. LVN A stated the fall mat for Resident #1 was implemented earlier in the day, and she was unaware HCNA C had not implemented the fall mat after providing care. She stated she rounded on all residents at least hourly to ensure fall prevention measures were in place. LVN A stated the potential harm to residents from not having care planned fall mats implemented was serious injury. In an interview with the DON on 9/16/2025 at 3:00 PM, she reported Residents #1 and #2 both had fall prevention care planning that included fall mats. She stated staff had made aware of the surveyor observation of Resident #2's fall mat not in place. She stated she spoke with CNA B, LVN A, and the physical therapy department regarding the fall mat, and she attributed the implementation failure to a temporary, agency staff member that she had terminated earlier in the day due to performance issues. The DON stated her expectation was that all staff, including facility employees, hospice, and agency, would implement care planned fall prevention measures at all times. She stated she ensured that any staff providing care for residents were given access to the electronic medical record system, including the Cardex which provided a synopsis of required interventions, including fall mats.Record review of the facility policy titled Accidents (undated, printed 9/16/2025) reflected the following:Individualized, person-centered interventions will be implemented, including adequate supervision and assistive devices, to reduce risks related to hazards in the environment.
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RIVER HILLS HEALTH AND REHABILITATION CENTER in KERRVILLE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in KERRVILLE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from RIVER HILLS HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.