Health inspection·January 19, 2024

F 0636 schedule; Level of Harm - Minimal harm or potential for actual harm Encourage and provide assistance to turn and reposition q 2 hours in PRN comfort; If transferring resident notify receiving facility of election of hospice and code status; Notify Hospice of resident and family request for Clergy support/visit, questions about dying process; Notify MD, Hospice of S/S of infection, injury and implement appropriate interventions within code status, Observe for S/S of impending death to include but not limited to: change in mental status, non-responsive, change in breathing pattern, change in heart rate, cyanosis (the change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed), mottling to extremities , decreased bowel sounds, increased lung sounds; Notify Hospice, RP, MD of change. Residents Affected - Few In an observation on 01/17/24 at 11:39 AM Resident #165 was lying in bed, moaning at times, unresponsive to verbal stimuli, not able to answer questions. Resident #165 appeared clean and showed no signs of pain or distress. Resident #165's family was at bedside. Resident #165 had blankets pulled to chest area with call light in reach. In an interview on 01/17/24 at 11:46 AM with Resident #165's FM she stated things had been ok with the care of Resident #165 and Resident #165 had been residing in the facility since December 21st. She stated she had no concerns with anything right now. She stated Resident #165 was on the downhill and nothing could be done. She stated Resident #165 was on Hospice care and she had no concerns with hospice. She stated Resident #165 recognized the hospice nurse when she came in. In an interview on 01/19/24 at 9:03 AM with the MDS nurse, she stated she was responsible for completing all MDS assessments. She stated Resident #165 was a new admission and Resident #165 admitted under hospice services. She stated that Resident #165's admission MDS assessment was miscoded and that she needed to correct it. She stated she had been trained on how to complete the MDS assessments and she did not believe there was any effects that could have been caused from the MDS assessment being coded incorrectly. She stated Resident #165 was private pay and if Resident #165 would have been on MCR or MCD, it may have affected Resident #165 or the facility differently in a financial way. In an interview on 01/19/24 at 9:37 AM with the ADM, he stated if a resident was on hospice services it should be coded as yes on the MDS assessment. He stated hospice not being coded on the MDS assessment would not affect the care provided for the residents. He stated he did not feel there would not be any issues if hospice was not coded on the MDS assessment. He stated he was made aware that Resident #165's MDS assessment was coded incorrectly, and they were going to perform an audit of all MDS's. He stated the MDS nurse was responsible for completing the MDS assessment and had been working in the facility for about two years. He stated the MDS nurse had been trained on how to complete an MDS properly and that the MDS nurse is an RN and should be ensuring the accuracy of the MDS assessments. In an interview on 01/19/24 at 11:08 AM with the DON, he stated the MDS nurse was responsible for completing MDS assessments and she had been trained on completing the MDS's correctly. He stated they had a corporate nurse that ensured the accuracy of the MDS assessments. He stated the MDS assessments should reflect if a resident was admitted on or was receiving hospice care. He stated if an MDS assessment was completed incorrectly, someone may not know if a resident was on hospice services. Record review of facility MDS 3.0 user's manual dated October 2023: CMS's RAI Version 3.0 Manual; page O-7, O01 10K1, Hospice care - Code residents identified as being in a hospice program for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 2 of 3 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 01/19/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675619 If continuation sheet Page 3 of 3