Health inspection·October 23, 2023

F 0686 2. Level of Harm - Minimal harm or potential for actual harm Determine and treat cause: Poor fitting shoes, blood sugar control, pressure area, infection. 3. Residents Affected - Some Ensure appropriate protective devices are applied to affected areas. 4. Monitor pressure areas for color, sensation, temperature. 5. Monitor/document wound size, depth, margins: document progress and wound healing on an ongoing basis. Notify MD as indicated. 6. Monitor/document/report to MD signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever. 7. Monitor/document/report to MD as needed changes in wound color, temp, sensation, pain, or presence of drainage or odor. 8. Petal space pulses with leg and foot ulcers. 9. Physician resident of affected area. Change position every two hours and PRN. 10. Refer to foot care nurse/podiatrist. 11. Treat wounds as per facility protocol. Review of Resident #1's previous facility orders dated 08/30/23 reflected order to cleanse open area to L heel and apply calcium alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed and cover with dry protective dressing each day shift. Review of Resident #1's admission Skin assessment dated [DATE] reflected pressure ulcer on L heel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 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 675619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 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 0686 no length, width, depth, or stage documented . Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's facility order audit report dated 10/23/23 reflected on 09/24/23 an order was placed for wound care: apply Calcium Alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed, cover with heel cup and wrap with stretch gauze. Skin prep entire heal everyday shift for weight loss for 30 days. Residents Affected - Some Review of Resident #1's MAR reflected wound care treatment for order began on 09/25/23. Interview with the DON 10/23/23 at 2:44 pm, revealed he was responsible for resident initial care plan or 48-hour care plan prepared for Resident #1. The DON revealed he just forgot to do it. He revealed it is important to do a resident care plan to make sure that all staff members know what is needed for the resident and for the residents to get the care they need. The DON revealed that it is the facility's policy to conduct an initial resident assessment and baseline care plan within 48 hours of the resident entering the facility. The DON was unaware that Resident #1 did not receive an order for treatment for her pressure ulcer until 3 days after her admission to the facility and treatment did not begin until 4 days after her admission to the facility. The DON revealed that if pressure ulcers are not care planned and go untreated, they could get worse, become infected, could become septic and the resident could be in pain. Interview on 10/23/23 with the ADON at 2:33 pm, revealed that it is facility policy that residents receive a skin assessment within 24 hours of entering the facility and the type of dimension, and stage of the pressure is documented. She revealed that if pressure ulcers are not treated, they could become septic and there is a danger of death. Interview on 10/23/23 with the wound care doctor at 3:01 pm, revealed the first time saw Resident #1 for wound care was on 09/26/23 and that her pressure ulcer was present prior to Resident #1's admission to the facility. The wound care doctor revealed Resident #1 was a high risk for pressure ulcers complications because she had diabetes and was a smoker. The wound care doctor revealed that these are the 2 highest risk factors involving pressure ulcer condition. He revealed it is important for the facility to assess residents upon admission because it is important to know what type of wound you are handling. Non treatment of a pressure ulcer with a diabetic resident condition could cause the wound to worsen and get infected could lead the overall progression of the disease . Interview on 10/23/23 with the ADM at 3:34 pm, revealed it was the policy of the facility that a in initial assessment upon admission and baseline care plan and skin assessment be performed on every resident within 48 hours of the resident's admission into the facility. Review of facility skin assessment policy undated reflected the facility is to provide a routine schedule of assessments for each resident skin assessment and ensure prompt identification and treatment for noted skin concerns. Assess the resident head to toe to identify all skin concerns to include but not limited to pressure ulcers of any type. For new skin concerns or worsening conditions notify the director of nurses, medical doctor, and family of any new skin concerns to include pressure ulcers. Implement appropriate treatments, interventions protocols or obtained appropriate treatment orders. Review of facility at baseline care plan policy undated revealed objectives: to ensure uniformity of concern approached by nursing home and team members. To help resident and their families be part of a team approach in ensuring residents needs and assessing with problems period to clearly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 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 675619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some delineate instructions and needed to provide effective and in person centered care of their resident that meet professional standards of quality care. Review of facility baseline care plan undated revealed nursing home staff will develop a baseline care plan for the resident's care within 48 hours of admission to the facility. The baseline care plan will include, at minimum, the following: initial goals based on admission orders and physician orders. Review of facility Preventing Pressure Ulcers Repositioning to Prevent and Treat Heel Pressure Ulcers policy undated revealed: inspect the heels at least daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 4 of 4