Health inspection·July 7, 2024

F 0686 Record review of Resident #1's EMR progress note on 6/1/2024 authored by Agency LVN A revealed Resident #1 had an open blister to right heel identified by facility a CNA. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's last skin assessment on 5/30/2024 revealed no issues. Residents Affected - Few Record review of Resident #'1's skin assessment dated [DATE] identified Stage 2 pressure injury to right heel 5.5cm x 8.2cm x 0.1cm with granulation tissue Record review of Resident # 1's skin assessment dated [DATE] indetified Stage 4 pressure injury to right heel, 3.2cm x 7.5cm x 0.1cm with necrotic tissue Record review of Residnt # 1 skin assessment dated [DATE] indetified Stage 4 pressure injury to right heel, 5.2cm x 7.2cm x 0.1cm with necrotic tissue. Record review revealed Agency LVN A did not obtain a physician order on 6/1/2024 for wound care. Record review of Resident #1's EMR revealed no documentation for deterioration in wound from 6/1/2024-6/4/2024. Record review of Resident #1's EMR revealed on 6/4/2024 wound care physician observed Resident #1's right heel to be a Stage 4 and ordered a wound care treatment plan. Record review of Resident #1's EMR revealed on 6/16/2024 Resident #1 was transferred to hospital for wound care debridement and due to maggots in wound. Resulting in a right below knee amputation. Record review of Resident #1's physician consolidated orders for 6/1/2024-7/2/2024 revealed no physician order on 6/1/2024 when right heel wound was identified. Record review of Resident #1's physician consolidated orders revealed Orders dated 06/02/2024 to Cleanse with wound cleanser, Apply TAO open area to patient;s right heel, dry dressing until healed. Start date 06/02/2024-06/03/0224 (Dc Date) Record review of Resident #1's physician consolidated orders revealed Orders dated 06/02/2024 to Cleanse with wound cleanser, apply CA alginate to open area to patient's right heel then dry dressing QD until healed Start date 06/03/2024006/04/2024 (Dc Date) Unable to reach Agency LVN A for interview after 2 attempts. Unable to reach Agency Nurse Aide B for interview after 2 attempts. During a telephone interview on 7/2/2024 at 10:28 am facility DON stated she was first informed of Resident #1 having a blister to his left heel on 6/1/2024. DON stated she saw Resident #1's wound to right heel on 6/1/2024 and determined a blister was present and advised Agency nurse to notify MD for treatment. During an interview on 7/2/2024 at 1:10 pm, Regional Nurse Consultant (RNC) stated if a nurse needed an order from a physician to provide care, the nurse would call the residents physician and then write the order so that it would transcribe to the resident's treatment record. She further revealed any orders written by nursing staff would transcribe to the Facility Activity Report and the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 2 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 - Immediate jeopardy to resident health or safety Residents Affected - Few would give report from shift to shift. When asked if there was an order written for Resident #1 [Heel cleaned with normal saline and covered with boarded gauze.} RNC stated I do not see one in the EMR until the next day on t 6/2, though the treatment was done on 6/1. She stated there should have been an order written. Unable to reach wound care physician for interview. During a telephone interview on 7/6/2024 at 9:10 am Resident #1's primary physician stated he was aware of Resident #1's right heel wound and further revealed he knew the wound care physician was addressing the treatment plan for Resident #1, prior to a right below the knee amputation. The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 7/5/2024 at 8:31 p.m. and a plan of removal was requested. On 7/6/2024 at 11:09 am, the facility provided a plan of removal that was accepted. It was documented as follows: On 7/5/24, a complaint survey resulted in Immediate Jeopardy (IJ). On 7/5/24, the administrator was provided with an Immediate Jeopardy template notification that the Regulatory Services has determined that the practice at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows; The facility failed to obtain a physician order for treatment and wound care for Resident #1 and the facility failed to assess and document residents wound care in a manner consistent with professional standards of practice and in accordance with the facility policy. On 7/5/24, the director of nursing in-serviced all licensed nursing staff regarding the policy when a new wound is identified. The licensed nurse will create an incident report, notify the physician to receive new orders, and enter those orders into the Matrix EMR. The licensed nurse will then enter the assessment of the wound into the Matrix EMR wound management system and notify the director of nursing and the resident's responsible party. Nursing staff not available for this in-service will receive it before starting their next assigned shift. Agency nursing staff will receive the training before starting their assigned shift. The in-service will be kept, to refer to, in the nursing 24hr book. On 7/5/24, under the direction of the director of nursing, a full facility skin sweep was completed on all residents. Any new areas of concern were documented per the facility policy listed above On 7/6/24, the facility DON in-service facility CNAs about notifying the charge nurse for any concerns with the resident's skin. Any CNAs not receiving the initial education will not be allowed to work their next assigned shift until they receive the information. On 7/6/24, the director of nursing in-service licensed nursing staff on how to complete a skin assessment. Agency nurses will receive this information before starting their next assigned shift and the information will be kept in the 24hr nursing book for reference. The director of nursing/assistant director of nursing will be responsible for reviewing the skin assessment documentation on any newly identified skin abnormality and re-educating when necessary. The regional nurse consultant will monitor compliance of the wound management system by reviewing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 3 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 the facility activity report, weekly, to identify concerns. Level of Harm - Immediate jeopardy to resident health or safety An Ad-Hoc QAPI meeting was held on 7/6/24, with the Medical Director, Regional Director of Operations, Director of Nursing, and the Regional Nurse Consultant to review the deficiency, policy and procedures, and the plan for removal of immediacy. Policies for monitoring the wound care system were discussed. Residents Affected - Few Verification: began 7/6/2024 at 11:30 am: 1. Record review on 7/6/2024 of Inservice titled Wounds Skin System with policy and procedure revealed signatures of 8 of 10 staff nurses and 4 agency nurses who attended the in service. 2. During an interview on 7/6/2024 at 11:40 am Regional Nurse Consult stated the 2 prn staff nurses would receive in service before working their next shift. 3. During interviews conducted on 7/6/2024 from 11:30 am - 3:30 pm with 6 day shift 6 am- 6pm nursing staff (LVN's RN ) an 6pm-6am nursing staff (LVN's RN) revealed they had been in-serviced on wounds , skin system with policy and procedures. . 1. Record review of Facility Wound Summary Report dated: 6/6/2024-7/6/2024 revealed current wounds being treated in facility were 1- Resident with Stage IV to right heel and left heel with measurements and orders for treatment. 1- Resident with arterial ulcer right heel with measurements and orders for treatment. 2. During an observation on 7/6/2024 at 11:13 am with RN treatment done to right heel of Resident in 608 per physician orders and infection control with no issues. Measurements and appearance were as documented on facility wound record dated 6/6/2024-7/6/2024. On 7/5/24, all current resident skin abnormalities were audited by the regional nurse consultant to validate that there was a physician's order and that the skin abnormality was in the wound management system and was being documented on. Any concerns were corrected immediately. 1. Record review of Facility Wound Summary Report dated 6/6/2024- 7/6/2024 revealed residents with a total of: 2 skin tear, 1 stage vii,3 other,1 arterial ulcer, 1 surgical incision, 1 abrasion,1 laceration. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 4 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Residents EMR dated 7/1/2024-7/6/2024 revealed residents on the Facility Wound Summary Report with current treatment orders. To total: 10 residents. On 7/5/24, the Regional Nurse Consultant re-educated the director of nursing and the assistant director of nursing regarding the process for monitoring and validating completion of nursing tasks in relation to skin abnormalities by reviewing the facility activity report, daily for new orders, as well as the dashboard of the EMR for any new incident reports. The wound management system will be reviewed weekly during the Quality of Care, meeting to validate completeness and to ensure wounds are entered correctly. Notifications will also be reviewed at that time. The ADON will be responsible for this process when the DON is not available. The Regional Nurse Consultant will attend the Quality of Care meeting weekly with the IDT for one month and randomly thereafter. The regional nurse consultant will be available for consultation when needed. Any concerns will be addressed immediately upon discovery. 1. During an interview on 7/6/2024 at 1:35 pm facility DON stated she was in serviced by the RNC regarding the process for skin system follow up and problem identification. 2. During an interview on 7/6/2024 at 1:36 pm facility ADON stated she was in serviced by the RNC regarding the process for skin system follow up and problem identification. During an interview on 7/6/2024 1:45 pm RNC stated we(Regional Director of Operations, DON and Administrator, RNC.) met this morning(7/6/2024), (Medical Director was not available ). During an interview on 7/6/2024 at 2:25 pm facility Administrator stated Medical Director had called him back and was informed of POR and IT . Medical Director told administrator he would see them at QAPI. The Administrator was notified of the IJ was identified on 7/5/2024. The IJ template was provided to the facility on 7/5/2024 at 8:26 pm. While the IJ was removed on 7/6/2024 the facility remained out of compliance at a scope of pattern and severity level of no actual harm because of the facility's need to evaluate the effectiveness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 5 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 1 of 4 residents (Resident #1) reviewed for pest control, in that: Residents Affected - Few The facility failed to ensure an effective pest control program was in place to keep flies out of resident rooms resulting in an infestation of maggots in Resident #1's right heel wound. The noncompliance was identified as PNC. The IJ began on 06/16/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the investigation began. The failure could place residents with wounds at risk for infection or infestations from pests. The findings included: Record review of Resident #1's electronic face sheet (printed 6/20/2024) revealed Resident #1 was admitted on [DATE]. His diagnoses included: pressure ulcer of right heal (stage 4 pressure injury a full-thickness wound with skin loss with extensive destruction, tissue necrosis, and damage to the underlying muscle, tendon, bone, or other exposed supporting structures.), unspecified dementia, protein-calorie malnutrition, UTI, cognitive communication deficit, pathological fracture right femur, iron deficiency, vitamin deficiency. Record review of Resident #1's MDS (Quarterly), dated 2/9/2024 revealed Resident #1 had a BIMS Score of 4, indicating severe cognitive impairment. Record review of Resident #1's Careplan, reflected the following: Potential for altered skin integrity related to dementia as evidenced by noncompliance of care (as of 2/14/2024). Goals included, Will have intact skin, with minimal redness, blisters or discoloration through review date. Interventions included, Notify family of any new areas of skin breakdown; Obtain and monitor lab/ diagnostic work as ordered. Report to MD and follow up as indicated; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bath or daily care; Body audits at least weekly by licensed staff. Record review of Resident #1's Careplan, reflected the following: Problem: (Resident #1) has a pressure ulcer to right heel (as of 5/8/2024). Interventions included, Wound care as per MD orders; Wound care physician to see (Resident #1) as needed; Position with pillows to elevate pressure points off the bed as needed; Turn and reposition resident throughout the shift. Record review of Resident #1's 6/16/2024 progress note revealed, (Resident #1) supine in bed refusing snacks and beverages. (Resident #1)had body temp of 99 at 2 PM and is now at 96.6. He is shivering as if cold even with blanket. His heart rate is 98, R20. (Resident #1) has low urine output today. Wound care done and (Resident #1) found to have necrotic tissue with maggots coming out of foot heel. Wound cleaned and dressed. MD notified and wants (Resident #1) to be sent to ER. Supervisor notified. (Responsible Party) notified and notification to (Hospital Staff) in ER. Interview on 6/19/2024 at 10:10 AM, the Administrator stated Resident #1 was not currently at the facility. The Administrator was asked if Resident #1 was at the hospital and stated that he was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 6 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Initial rounds on 6/19/2024 at 10:54 AM, staff were appropriately engaged with residents, staffing appeared sufficient, no profuse or lingering odors were detected. No flies or other insects were observed during these rounds. Observation on 6/19/2024 at 12:15 PM of the dining area during lunch meal service Reveal no flies or insects in the dining area. Residents Affected - Few Interview on 6/19/2024 at 12:20 PM, the Administrator stated interventions had been put into place including electric fly traps on the interior of the building, air curtains, and water traps, which utilized yeast to attract and trap flies on the exterior of the building. The administrator stated that when the temperatures became warmer outside along with the additional rain, some flies had been able to enter the building when residents would exit and enter the building during smoke breaks. He said they recently had pest control treat the facility for this issue. Observation and attempted interview on 6/19/2024 at 1:29 PM, of Resident #1 at the hospital revealed Resident #1 was in bed sitting in an upright position. Resident #1 appeared clean and well kept. Resident #1 did not exhibit any s/s of pain or grimacing. During an interview at this time, Resident #1 did not respond to questions but stared blankly at the wall. Interview on 6/19/2024 at 1:35 PM, Hospital RN A stated Resident #1 was recently admitted several days ago with a necrotic wound to his heal which resulted in a below the knee amputation. Hospital RN A said Resident #1 was currently on isolation precautions with dx, ESBL of the urine and was not alert or oriented. Interview on 6/19/2024 at 2:05 PM, Hospital DR B, stated Resident #1 was admitted to the hospital with a stage 4 ulcer to his heal. The Hospital DR B said it was likely acquired following surgery for hip fracture in April of 2024. Hospital DR B said it was likely that given Resident #1's dementia and comorbidities, he was likely more prone to acquiring that type of an injury. Interview on 6/19/2024 at 2:21 PM, Hospital DR C, stated he was a part of Resident #1's hospital admission and stated that in his professional opinion, he did not believe that the presence of maggots to Resident #1's wound had an impact on the outcome of Resident #1's below the knee amputation, indicating Resident #1 would likely have had to have the amputation even if the maggots were not in Resident #1's wound. Hospital DR C opined that the resident had multiple diagnoses that made him more susceptible to acquiring said wound. Interview on 6/20/2024 at 11:43 AM, Treatment Nurse, LVN C said she was reassigned to Resident #1's Hall on 6/16/2024 and said upon removing Resident #1's dressing for treatment, she discovered approximately 5 maggots on his wound. LVN C said she then called the Resident #1's physician and subsequently sent Resident #1 to the hospital. Observation and interview on 6/20/2024 at 12:05 PM, Resident #2 was observed sitting in his bed watching the television. Resident #2 appeared clean and well kept. No s/s of pain or grimacing were observed. Resident #2 was asked how long he had been at the facility and responded, since May. Resident #2 was asked if he had any concerns regarding fly infestations and responded that he would occasionally see flies but that it had improved. Interview on 6/20/2024 at 2:15 PM, the Administrator stated about 2-3 weeks ago the facility became overwhelmed by flies, likely due to the weather conditions and the frequency with which the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 7 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents who smoked would open and close the door leading to the smoking area adjacent to the dining area. The administrator was asked if Resident #1 would leave his room and responded that staff would wheel Resident #1 to the dining area for meals and to watch television. Observation and interview on 6/20/2024 at 3:18 PM, Resident #3 was observed watching television in her room. Resident #3 appeared clean and well kept. During an interview at this time, Resident #3 was asked if she had any concerns specific to flies in the facility. Resident #3 grabbed a fly swatter and said several weeks ago, they were really bad. Resident #3 said the fly infestation seemed have improved. Telephone interview on 6/20/2024 at 3:32 PM, Wound Care Physician, TDR E, said he worked on Resident #1's wounds once per week and said he had no concerns specific to the care Resident #1 was receiving. TDR E said Resident #1's wounds were covered on every visit he had with the resident. TDR E said that at times Resident #1 seemed non-compliant and combative so may have removed coverings on those occasions but was never something he had observed. TDR E was asked how long it would take for a fly larvae (maggot) to hatch once the egg was laid and he responded, approximately 7-24 hours. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR dated 6/18/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, and HHSC. Record review dated 6/17/2024- 46 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Wound Information. STAFF INTERVIEWS ON TRAINING: 6/20/2024 from 3:30 PM to 6:00 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 6/20/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the maggot identification, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed flies and/or maggots and to let the charge nurse know if either was identified. On 6/20/2024, the Administrator was interviewed and revealed all interventions that the facility proactively put into place in response to pest control which included the purchase of air curtains, electronic fly traps, water traps, baiting around the exterior of the facility, trash cans, and dumpsters, and a treated wipe down of the entire facility. Observation rounds were conducted on 6/20/2024 and revealed screens were on all resident windows on the 500 hall, trash cans and dumpsters were located at an appropriate distance from the facility, electronic fly traps were activated, and the facility appeared to be free of fly infestations. Sampled residents were also interviewed and stated significant improvement specific to the presence of flies at this facility. Record review of a document, not dated, revealed an invoice, not titled. Further review of this document stated, Order placed 6/4/2024 in the amount of $422.16, and stated, Arriving Friday - [NAME] WS-95 Wall Sconce Flight light Trap Lamp . Record review of a document, titled, Order Summary, dated 6/5/2024, stated, Fly bait used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 8 of 9 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0925 Level of Harm - Immediate jeopardy to resident health or safety control fly problem at facility. Suggested by pest control. Further review of section, Total, revealed a charge of $63. Record review of document titled, Additional Service/Equipment Proposal, Commercial Pest Management Program, dated 6/17/2024, stated, Service needed for - Flies. Section, Estimated Price of Proposed Services, stated, Targeted Fly Wipe-down $300 . Full Facility Wipe-down - $750. Residents Affected - Few Record review of a facility policy, Flies, not dated, stated, Sources - open exterior doors, filth, smoking patios, dumpsters/garbage . Control Methods - Keep doors closed; keep dumpsters closed and trash-drip area clean; frequently power wash dumpsters/smoking areas and empty ashtrays . Record review of a facility policy, Fly Protocol, not dated, stated, There is not a single tactic that can keep flies out. It requires using a combination of multiple chemicals and equipment, along with diligent good habits from the facility to keep flies mitigated The noncompliance was identified as PNC. The IJ began on 06/16/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the investigation began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 9 of 9