Health inspection·November 17, 2023

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** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of five residents reviewed (Resident #1, #2, and #3) for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #1's humidifier for the oxygen concentrator had water. 2. The facility failed to ensure Resident #1's nebulizer mask was bagged while not in use. 3. The facility failed to ensure Resident #2's oxygen tubing was changed weekly as ordered. 4. The facility failed to ensure Resident #3 had an oxygen sign posted outside her bedroom. These deficient practices could place residents at risk for inadequate care and respiratory infection. Findings include: 1. Record review of Resident #1's face sheet, dated 11/17/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included presence of unspecified artificial knee joint, Osteoarthritis (tissues in the joint break down over time), Hypertension, Heart failure, Hyperlipidemia (high fat level in blood), Localized Edema, Abnormal weight loss, Atrial fibrillation (irregular heart rhythm), Anemia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (problems that cause breathing difficulty), Dementia, Psychotic Disturbance, Mood disturbance and Anxiety. Record review of Resident #1's quarterly MDS assessment, dated 09/19/23, reflected a BIMS of 8, which indicated her cognition was moderately impaired. Section O (Special Treatments, Procedures, and Programs) reflected she received respiratory therapy 7 days a week. Record review of Resident #1's quarterly care plan, revised 09/20/23, reflected: Resident is at risk for shortness of breath, respiratory distress, increased anxiety due to Dx COPD. and the relevant interventions were: Provide O2 as ordered and indicated .Provide NEB/inhalers as ordered. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 675619 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 11/17/2023 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)