Health inspection·February 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents. (Resident #34) The facility failed to develop an accurate care plan for Resident #34 smoking and renal disease. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of the face sheet dated 02/17/25 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and high blood pressure. Record review of the physician orders dated February 2025 indicated Resident #34 did not have orders to be sent for dialysis (a medical treatment that removes waste and excess fluid when the kidneys are not functioning properly) treatments. Record review of a significant change MDS assessment dated [DATE] indicated Resident #34 was able to understand and was understood. The MDS indicated a BIMS score of 13 indicating Resident #34 was cognitively intact. Resident #34 required a walker to ambulate and supervision for some ADLs. Dialysis was not checked on the form which would have indicated dialysis was being received on admission or during last 14 days. Record review of Resident #34's care plan initiated on 05/03/24 indicated Resident #34 had a diagnosis of renal disease. The resident was at risk for complications related to having a shunt (an artificial passageway allows blood to flow to another area). The interventions included checking the shunt access site dressing after dialysis for uncontrolled bleeding, redness, swelling, and for decreased bruit at the shunt site, notifying the physician of abnormal findings, and to encourage and allow the resident to rest as needed post dialysis, ensure the resident was ready for dialysis on (day), (day), (day), and to remind dietary of need for a to go meal to take with them to dialysis. Record review of Resident #34's care plan was initiated on 01/09/25 indicated the resident smoked cigarettes. The interventions indicated to remind the resident and family that all cigarettes, (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 5 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 02/19/2025 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)