Inspection·May 15, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few secondary complications. Review of the facility care plan records reflected that the Comprehensive Care Plan was due on 4/18/25, which was 7 days after the comprehensive assessment and within the 21-day window from admission. In an interview on 5/15/25 at 4:49 PM MDS stated, the 4/8/25 care plan for Resident #1 was a baseline care plan and it was not updated since there were no changes. She stated that she was responsible for maintaining the care plans on residents. She stated the purpose of the care plan is to tell staff how to care for the resident and a negative outcome to the resident if care plans are not done was that the staff would not know what the resident needs or likes. MDS stated that she was unaware that a comprehensive care plan was due within 21 days of admission. In an interview on 5/15/25 at 5:19 PM LVN-A stated that use of oxygen for a resident should be reflected on the care plan. She stated the policy and purpose of care plans is to make sure all staff are on the same page and working towards the same goal for residents. LVN-A stated the negative outcome to residents if care plans are not kept current could be staff confusion or failure to meet the needs of the resident. In an interview on 5/15/25 at 5:35 PM CNA stated the negative outcome to residents if the care plan is not current could be a drop in the health of the resident and the main purpose of the care plan is to make sure they are getting up and living their best life. In an interview on 5/15/25 at 5:47 with the DON who stated the purpose of care plans was to ensure all staff are working on the same goal with residents and to know where they are headed. She stated care plans should be done on admission, a comprehensive care plan within 21 days of admission, quarterly and when a change of condition occurs. She said the negative outcome to residents if the care plan was not kept current was that staff would have no guidance on care for the residents. In an interview on 5/15/25 at 6:05 PM with ADM, who stated the policy and purpose of care plans was to provide individual plans of care to tell staff how to care for and what should be done for residents. She said care plans should be revised as needed and it was a living document-always changing. She said care plans should be done Initial Base Line on admission, then Comprehensive care plan and thereafter Quarterly. She stated the negative outcome to residents if the care plan was not current was the resident would not receive the appropriate care. Record Review of the facility policy titled, Care Plans, Comprehensive Person-Centered and dated March 2022, reflected: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 2 of 4 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Acronyms: HTN Residents Affected - Few COPD MDS DON ADM LVN BIMS Based on observations, interviews, and record review the facility failed to ensure that the resident's record reflected an ongoing assessment of the resident's respiratory status, a practitioner's order, and indications for use of oxygen for 1 of 1 resident (Resident #1) reviewed for oxygen therapy. The facility failed to ensure Resident #1's chart reflected a practitioner's order for oxygen indicating the amount and flow type for Resident #1's use of oxygen. There was no oxygen assessments in the chart for Resident #1's diagnosis of COPD. This failure placed residents at risk of developing respiratory distress by receiving too much or too little oxygen . Findings included: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), Dementia, Diabetes Type 2, HTN, and Hypothyroidism. Review of Resident #1's Quarterly MDS dated [DATE] reflected her BIMS score was 05, which indicated severe cognitive impairment. Review of Resident #1's Care Plan dated 4/18/25 reflected a care area initiated for Risk for COPD Complications with a goal to remain free of secondary complications. There was not a care area shown for oxygen therapy. Review of all of Resident #1's orders from admission on [DATE] to 5/15/25 did not reflect any orders for oxygen therapy. Review of Resident #1's vital signs flow sheet from 4/7/25 to 5/15/25 reflected her oxygen saturation level was charted on 4/8/25, 4/12/25, 4/13/25, 5/5/25, and 5/6/25 with the indicator that she was using oxygen via a nasal canula when the saturation level was checked. All saturation levels were between 90% -100%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 3 of 4 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 5/15/25 at 10:49 AM of Resident #1's room revealed an oxygen concentrator machine in the room by the resident's bed with clear, clean nasal canula tubing attached to it. In an interview on 5/15/25 at 4:43 PM Resident #1 stated that she does not know how to use the oxygen concentrator machine and that she does not remember using but she also stated that she has trouble recalling some things. In an interview on 5/15/25 at 4:49 PM MDS-LVN stated she was unaware of the oxygen machine in Resident #1's room and unsure if the resident uses the machine. She stated she was responsible for updating the care plans for residents and the oxygen was not indicated on the care plan. In an interview on 5/15/25 at 5:19 PM the LVN stated that use of oxygen for a resident should be reflected on the care plan and oxygen requires a physician's order. She stated Resident #1 does not keep oxygen on now, but she was wearing oxygen when she was first admitted . She knew there was not a current order for her oxygen. She stated the negative outcome to residents if oxygen was given without an order was that the resident's oxygen could be set too high for a COPD patient. She said the limit was 4 liters per minute for a COPD diagnosis and if it was too high the resident could have trouble breathing. In an interview with the CNA on 5/15/25 at 5:35 PM who stated oxygen should be reflected on the care plan. She stated Resident #1 wore oxygen on her first day here, but not since. She stated the negative outcome if oxygen was not ordered could be death to a resident. In an interview on 5/15/25 at 5:47 PM with the DON who stated, oxygen requires an order and should be indicated on the care plan also. She stated the negative outcome to residents if oxygen was not ordered was that it may not be given when needed or a resident with COPD could get too much oxygen, which could cause harm. In an interview on 5/15/25 at 6:05 PM with ADM who stated that oxygen should have a physician's order and should be indicated on the care plan. She said the negative outcome to residents if there was not an order could be incorrect treatment. She stated oxygen therapy was driven by the physician's order to determine what we are allowed to do with it. She stated determining oxygen therapy was beyond her scope of practice. Record Review of the facility policy titled, Oxygen Administration and dated 2001 with last revision date of October 2010, reflected: Verify that there is a physician's order for this procedure (Oxygen). Before administering oxygen, and while the resident is receiving oxygen therapy, assess for cyanosis (blue skin), hypoxia (low oxygen), or oxygen toxicity (difficulty breathing/shallow rate of breathing). After setting up oxygen, document date, time, name, rate of flow, route, frequency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 4 of 4