Luling Care Center

5/5/25

On 5/5/25, an abbreviated survey was re-opened at facility. On 5/5/25, the surveyor provided an immediate jeopardy (IJ) template notification that the regulatory services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.

The notification of Immediate Jeopardy states as follows: The facility failed to ensure Resident #1s bed was

in the lowest position and had fall mat in place when he fell on [DATE REDACTED] and fractured his left hip.

Resident #1s fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition.

On 5/5/25, the Regional Nurse Consultant/ADON, reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex. The RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions.

This audit was documented utilizing the PCC Fall Assessment score report. Twelve (12) additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex.

On 5/5/25, the RNC/administrator educated 100% of facility staff regarding where to find the information for fall interventions. Staff not receiving the initial education will receive if before starting their next assigned shift. Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex. 100% of the interdisciplinary team (IDT) were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting. The IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions. The administrator verified the initial Comprehension of staff training by questioning staff and documenting it on an audit form. The administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/06/2025 Avir at Luling 501 W Austin St Luling, TX 78648 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

The RNC will review falls weekly, for one (1) month to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex. Any concerns will be corrected immediately and re-education given to the management team. This will be documented on an audit flow sheet.

Education understanding will be completed three (3) times a week for one (1) month by the administrator by questioning the facility staff about where they can find the fall intervention information. The RNC will complete education understanding with the management IDT by questioning them two (2) times a week for one (1) month regarding IDT rounds and identifying problems with fall interventions specifically. This will be documented on an audit flow sheet.

On 5/5/25, an Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal.

A&B) Monitoring for the POR occurred on 04/17/2025 and 04/18/2025 as followed:

Observation on 04/17/2025 at 10:05 AM, revealed door was secured and required a code from staff to answer or exit.

Observations conducted between 04/17/2025 and 04/18/2025 reflected ongoing 1:1 oversight with Resident #2 and staff.

Review of Ad.Hoc QAPI sign-in sheet dated 04/16/2025 reflected meeting completed.

Review of Resident #2's care plan reflected he was a high elopement risk and interventions included 1:1 oversight.

Review of in-service dated 04/16/2025 by regional nurse completed with ADM, and DON reviewed within 24 hours of admission, elopement assessment must be reviewed by nursing administration for any resident deemed high risk for elopement and communication with staff. New employees with receive the training on high risk residents and where to find the information, interventions and communication.

Review of in-service dated 04/16/2025 completed with all staff reflected Resident #2 was a high risk for elopement and was currently on 1:1. In-service included any resident who had the potential to elope must be reported to the ADM immediately for interventions to be implemented. Information regarding elopement could be found on Kardex on PCC and in the resident's care plan. Resident deems high risk will have a care plan formulated, added to Kardex in PCC and verbal communication with front line staff.

Review of in-service dated 04/16/2025 completed with nurses reflected any resident who scored a 10 or high

on elopement assessment or exhibits any elopement possibilities must be communicated to the ADM and DON immediately and interventions will be put in place and communicated to staff.

Review of Audit Log dated 04/18/2025 reflected six employees were tested for retention over in-service and elopement.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/06/2025 Avir at Luling 501 W Austin St Luling, TX 78648 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

During interviews conducted between 04/17/2025 and 04/18/2025, 4 LVNs, 4 CNAs, 1 HSK ADON, DON, ADM and regional nurse, revealed that Resident #2 is the only resident currently a high risk for elopement and he currently is on 1:1. Staff interviewed stated they can determine who was a high elopement risk by looking at the resident's Kardex or in PCC. Nurses interviewed stated that any resident who scored a 10 or high and was deemed a high elopement risk on the elopement assessment would notified the DON and ADM immediately. Staff stated that any changes in behavior or increase in wandering should be notified to the charge nurse and then the DON and ADM immediately.

During interviews conducted on 04/18/2025, regional nurse, DON and ADM stated that any new admission will be reviewed by regional nurse within 24 hours. They stated nurses have been in-serviced to notify the DON and ADM immediately of any residents who scored high-risk for elopement. The care plan should also be updated and this included their baseline care plan. Resident #2 was currently 1:1. They stated education will be on going and staff will be tested for retention.

C)Monitoring for POR occurred on 05/06/2025 as followed:

Review of 12 residents identified as at risk for falls indicated fall evaluation was completed and care plans included that the residents were a fall risk and interventions for each resident.

Review of in-service sign-in sheet dated 05/05/2025 at 05/06/2025 reflected subject of fall interventions completed with staff on shift and prior to the start of their next shift. Information reviewed included staff is to ensure residents are safe by ensuring their fall interventions are always in place. Nurses can find residents fall interventions on their care plan as well as the resident Kardex in PCC. CNAs can find fall interventions on

the resident point of care Kardex in PCC. Staff should round at the start of their shift and at least every two hours to ensure listed fall interventions are in place. In-service included list of residents who had interventions in place such as a low bed or fall mat.

Review of initial comprehension questionnaire dated 05/05/2025 and 05/06/2025 reflected ADM tested comprehension of POR information reviewed with nurses, aides and IDT.

Review of QAPI meeting dated 05/05/2025 reflected IDT members and medical director attended.

Review of in-service sign-in sheet dated 05/05/2025 reflected subject of fall interventions and rounds completed with IDT reflected IDT should round prior to the morning meeting to assigned ground of rooms and weekends when assigned as weekend manager. Rounds include fall hazards in the resident room, medications at bedside, water or fluid on the floor, anything left out that can be a hazard, fall interventions and to notify nursing management / administrator if interventions are not in place.

During interviews on 05/05/2025 with IDT members, BOM, HR, AD, maintenance director and DOR reflected

they were provided a list of residents who had fall interventions in place and were responsible to round prior to morning meeting during the week and on weekends when assigned weekend manager. IDT members stated that they can also find fall interventions in the residents care plans. IDT members stated that if interventions were not in place and it was something they could fix they would fix it, but if not they would notify the nurse, ADM or DON.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/06/2025 Avir at Luling 501 W Austin St Luling, TX 78648 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

During interviews on 05/06/2025 with 2 CNAs, 2 LVNs, and 1 cook reflected they received an in-service on fall interventions on 05/05/2025 or 05/06/2025 provided by the ADM. Staff stated that they can find fall interventions on the Kardex in PCC or in the resident's care plan. They stated they should round at least every two hours and at the beginning and end of their shift and look that fall interventions are in place. Staff stated they can fix interventions they see out of place and if they see something that could cause harm they would notify the ADON or ADM.

During an interview on 05/06/2025 at 3:49 PM, regional nurse stated that ADM would in-service any agency or new hire staff prior to working their first shift on falls and interventions. Regional nurse stated that when fall interventions are put in place, the Kardex and care plan would be updated and an updated IDT list would be provided by the ADM and discussed during morning meeting. She stated staff will have comprehension completed two times a week for a month. Regional nurse stated that falls would be reviewed during daily IDT and discussed and regional nurse until a DON is hired. Regional nurse stated if an issue were found during a fall audit depending on the issue, remedy could include re-educate, if incident report had issue nurse would be reeducated if care plan didn't have interventions MDS nurse would be educated.

During an interview on 05/06/2025 4:04 PM, ADM stated that agency or new staff would be informed of residents who were at risk for falls by ongoing fall prevention in-service being included on the 24-hour report to catch any new or agency staff. ADM stated staff would be informed of update during morning h [TRUNCATED] 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/06/2025 Avir at Luling 501 W Austin St Luling, TX 78648 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 of (03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025 ) 33 days reviewed for RN coverage.

The facility failed to ensure they had an RN charge nurse on 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025.

This failure could place residents a risk of missed nursing assessments, interventions, care and treatment.

Review of daily sign-in schedule for March 15, 2025 through April 17, 2025, reflected zero hours work by an RN charge nurse on the following days: 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025.

During an interview on 04/17/2025 at 3:20 PM, the ADON reflected that between 03/15/2025 and 04/17/2025 there was not an RN that worked at the facility on the weekends. The ADON stated between that time, an agency RN worked on 04/05/2025 and the DON was at the facility on 04/05/2025 and 04/06/2025.

During an interview on 04/17/2025 at 4:49 PM, the ADON stated that she was responsible for MDS, transportation, staffing/scheduling and worked as an ADON. The ADON stated that the facility had no circumstances that required an RN onsite. The ADON stated if the facility did, they would reach out to regional nurse and DON as they lived close by. The ADON stated she did not know what the protocol was when the facility did not have an RN available to work the required 8 consecutive hours a day. The ADON stated the facility did not get residents who were a high acuity, so the facility did not have residents that required services provided by an RN.

During an interview on 04/17/2025 at 4:57 PM, the DON stated that the facility had no had any care come up that required an RN. The DON stated she would have handled it if something came up that required RN intervention. The DON stated that she brought up to management that the facility needed an RN for weeks and stated the facility tried to actively hire an RN for coverage on the weekends. The DON stated she was at

the facility Monday through Friday from at least 8:00 am to 5:00 pm and usually longer.

During an interview on 04/17/2025 at 5:16 PM, the ADM stated the facility did not take on any resident who required 24 hour RN care. The ADM stated if there was items that needed to be completed by an RN the DON or regional nurse would come in or the DON from a nearby sister facility. The ADM stated that the facility had an ongoing job posting on several platforms. The ADM stated that he tried to employee an RN for years but because of the rural area it made it difficult. The ADM stated the facility did not have a weekend RN that came into work.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/06/2025 Avir at Luling 501 W Austin St Luling, TX 78648 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 04/17/2025 at 5:17 PM, regional nurse stated the facility did not have a specific policy regarding RN coverage and that the facility followed state guidelines. 08/27/2025