Health inspection·October 27, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm -Escitalopram Ozalate Tablet 5MG, Give 1 tablet by mouth one time a day for depression, dated 12/23/21, by prescriber. -Alprazolam Tablet 0.5 MG, Give 1 tablet by mouth three times a day for anxiety, dated 06/28/22, by prescriber. Residents Affected - Some -Side Effects to antianxiety medication, monitor day and night shift, dated 08/02/22, by prescriber. -Side effects to antidepressant medications, monitor day and night shift, dated 08/02/22, by prescriber. Review of Resident #27's care plan dated 09/06/22, did not reflect Resident #27's use of anti-depression or anxiety medication or monitoring for side effects. 2.Review of Resident #34's face sheet, dated 10/27/22, revealed, he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: encephalopathy (disease of the brain), cerebral infarction (stroke), depression, and seizures. Review of Resident #34's MDS assessment, dated 08/22/22, revealed, his BIMS was 4 (severe cognitive impairment). His active diagnoses included: Cerebrovascular accident (stroke), seizure disorder, malnutrition, encephalopathy (disease of the brain), and depression. Review of Resident #34's Orders Summary Report, dated 10/27/22, did not reveal advance directive orders. Review of Resident #34's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form, dated and signed by responsible party on 09/27/21, revealed Resident #34's advance directive wish was do not resuscitate. Review of Resident #34's care plan, dated 08/17/22, reflected Resident #34's advance directive of Full Code initiated on 04/20/21. 3.Review of Resident #36's face sheet dated 10/27/22, revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: cerebrovascular disease (condition that affected blood flow and vessels in the brain), adult failure to thrive, depression, anxiety, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #36's MDS assessment. dated 09/12/22, revealed his BIMS was 3 (severe cognitive impairment). His active diagnoses: Hypertension (high blood pressure), hyperlipidemia (high cholesterol), malnutrition, anxiety disorder, depression, and cerebrovascular disease. His active special treatment: Hospice care. Review of Resident #36's Order Summary Report dated 10/27/22, revealed the following orders: -Admit to Oaks Nursing Care (ONC) under the care of [Hospice Company], dated 09/03/22, by prescriber. -DNR, dated 09/03/22, by prescriber. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 2 of 5 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 675619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burnet 507 W Jackson St Burnet, TX 78611 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #36's care plan dated 09/26/22, revealed no focus area, goal, or interventions for hospice care. 4.Review of Resident #44's face sheet, dated 10/27/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: nontraumatic intracerebral hemorrhage in hemisphere, subcortical (stroke), chronic obstructive pulmonary disease (lung disorder), hyperlipidemia (high cholesterol), and Type 2 diabetes mellitus with other diabetic neurological complications. Review of Resident #44's MDS assessment, dated 10/03/22, revealed his BIMS was 15 (cognitively intact). His active diagnoses included: diabetes mellitus, hyperlipidemia (high cholesterol), cerebrovascular accident (stroke), malnutrition, and chronic obstructive pulmonary disease. Review of Resident #44's clinical record revealed no evidence of a care plan completed. 5.Review of Resident #54's face sheet, dated 10/27/22, revealed he was an [AGE] year-old male who was originally admitted to the facility on [DATE]. His diagnoses included: pneumonia, weakness, hypertension (high blood pressure), anxiety, hypokalemia (low potassium level), and acute respiratory failure. Review of Resident #54's MDS assessment, dated 10/03/22, revealed his BIMS was 10 (moderate cognitive impairment). His active diagnoses included: hypertension (high blood pressure), malnutrition, anxiety, respiratory failure, hypokalemia (low potassium level), weakness. His active special treatment: Hospice care. Review of Resident #54's Order Summary Report dated 10/27/22, revealed the following orders: -Regular Diet: Mechanical soft texture, honey consistency, for swallowing issues, dated 10/14/22, by prescriber (verbal). -DNR, dated 10/03/22, by prescriber (written). -Morphine Sulfate (concentrate) solution 20 MG/ML, give 0.25 ml by mouth every 2 hours as needed for pain; shortness of breath, wheezing, dated 09/30/22, by prescriber (written). -Lorazepam Tablet 1 MG, Give 1 tablet by mouth every 4 hours as needed for anxiety or agitation. -Norco Tablet 5-325 MG (Hydrocodone-acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain, not to exceed 3 Grams of Acetaminophen in 24 hours. Resident #54's Order Summary Report did not have hospice services identified. Review of Resident #54's written orders in electronic health record system revealed a scanned copy of an order stated: Admit [Resident #54] to [hospice company], dated 09/28/22. Review of Resident #54's care plan, dated 09/28/22, revealed the following: - Focus: At risk for/history of weight changes and malnutrition to: protein calorie malnutrition, dated initiated: 07/28/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 3 of 5 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 675619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burnet 507 W Jackson St Burnet, TX 78611 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 0656 - Intervention: Regular Diet, Mechanical soft texture, thin liquids dated 08/03/22. Level of Harm - Minimal harm or potential for actual harm Resident #54's care plan inaccurately identified advance directive of Full Code dated 07/28/22 as there was an active DNR order dated 10/03/22. Residents Affected - Some Resident #54's care plan did not have a focus, goal, or intervention/tasks for hospice services, narcotic medication, or anxiety medications. An interview on 10/27/22 at 12:49 PM with the DON revealed he worked for the facility since 2014. The DON stated initially the care plans were the responsibility of the MDS Coordinator. However, the facility had been without an MDS Coordinator for about a month. The DON stated the Director of Clinical Reimbursement (DCR/Corporate) was coming two times a week to ensure MDS assessments and care plans were maintained. The DON stated, during the time of not having an MDS nurse, he or the DCR were responsible for care plans. The DON stated if a resident went on hospice, he would create the referral and then when the family or resident agreed to hospice services, the hospice company provided him the paperwork and it was his responsibility to put the order into the system and update the care plan. The DON stated if the information was not in the care plan or electronic orders, the nurses could refer back to a paper chart. However, the DON reviewed Resident #54's paper chart, and there was no order present. The DON stated he was not sure what happened, but it appeared this slipped through the cracks. The DON stated the risk of not showing hospice orders, or any other individualized area, the nurses would not know the residents were on hospice, or who to notify or how to properly care for the residents. The DON stated a resident's diet, use of narcotics, anti-anxiety or depression medications, should be in the care plan. The DON stated again the risk of not having these areas on the care plan puts the residents at risk for not getting the services they deserve. The DON stated no one ultimately reviewed his work, he was trusted to input information accurately. An interview on 10/27/22 at 2:04 PM with the Administrator revealed he worked at the facility since August 2022. The Administrator stated he did not attend care plan meetings as a rule, but if there was a particular concern or need, he would be in attendance. The Administrator stated he did not input care plans. He relied on the DON and/or MDS Coordinator to input and update care plans as needed. The Administrator stated their past MDS Coordinator went back to being a floor nurse about a month ago as she was burnt out from completing MDS assessments and the lack of attention to detail was observed. The Administrator stated while they did not have an MDS Coordinator the facility relied on the Director of Clinical Reimbursement (DCR) and the DON to update and input care plans. The Administrator stated it was important to have accurate, individualized care plans for the residents because it tells the story of the resident. The Administrator stated if the care plans were not accurate, the resident was at risk for not receiving the individualized care they deserve. The Administrator stated, previously he knew there was an issue regarding accurate care plans, but thought the facility had resolved this deficiency. The Administrator stated he ultimately was responsible for all things in the building but to ensure the accuracy of care plans would fall on his DON. An interview on 10/27/22 at 2:23 PM with MDS Coordinator, revealed she was an RN and worked for the facility as a floor nurse since 2016; however, she was not hired for this position until 10/06/22, and she was still learning her position as she has never input an MDS. MDS C stated she could not speak to the accuracy of care plans prior to this date but would recommend the surveyors contact the DCR as she was training her for this position and completed care plans during the time of not having an MDS Coordinator. An interview on 10/27/22 at 2:25 PM with the DCR revealed she was an LVN and worked for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 4 of 5 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 675619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burnet 507 W Jackson St Burnet, TX 78611 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility for over 13 years and was promoted to Director of Clinical Reimbursement about 1.5 years ago. The DCR stated she filled in as the MDS C at the facility from the first part of September until the new MDS C was hired on 10/06/222. The DCR stated she was still very involved in care plans and MDS assessments as the new MDS Coordinator had no experience. The DCR stated she would physically be at the facility two times a week for resident/family interviews and would continue to work on the care plans and MDS when she was not assisting her other facilities. The DCR stated when she began reviewing the care plans in September she saw a deficiency and she continued to try to get the care plans caught up. The DCR stated care plans should include all areas listed in the MDS to include, hospice, diet, ultimately anything that required a physician's order. The DCR stated care plans were important because that was how the staff knew how to care for the residents. The DCR stated if the care plans were not accurate the staff could not meet the needs of the residents appropriately or in a timely manner. Review of facility policy titled: Comprehensive Care Plans, undated, revealed the following: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being, b. Any services that would otherwise be required but are not provided due to a resident exercising their right to refuse treatment and services . 3. The comprehensive care plan will be: a. Developed within 7 days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility (See Baseline Care Plan Policy) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 5 of 5