Health inspection·March 14, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents choice to activities, schedules (including sleeping and waking times), healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to honor Resident #1's request to be assisted out of bed at least once a day. This failure could place residents at risk for depression, diminished quality of life and isolation. Findings included: Record review of Resident #1's face sheet dated 03/14/2025 revealed an admission date of 07/23/2021 with latest re-admission on [DATE], and with diagnoses which included: Cerebral infarction (stroke); Hemiplegia (weakness or paralysis on one side of body)affecting right dominant side; Aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction; Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood); and Morbid obesity due to excess calories (Body Mass Index of 40 or higher which can increase risk of serious health problems and can shorten lifespan). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was left blank, and she was assessed as being dependent for transfers and mobility with wheelchair. Record review of Resident #1's Care Plan dated 01/29/2925 revealed a problem area which included: - Resident requires use of hoyer/mechanical lift and is at risk for injury, with intervention of 2 staff at all times for transfer with mechanical lift; and - Resident has low attendance in activities, goal Resident will attend activities 1xw. Record review of Resident #1's Physician Orders dated 03/14/2025 revealed an order for Resident may attend activities and social events of choice and ADL-Transfer: Total dependence x2 [mechanical] lift Record review of Resident #1's vital signs record revealed her current weight is 316lbs., down from Page 1 of 5 675641 675641 03/14/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0561 328.2 lbs in December 2024. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Point of Care History for ADL's -Transfers from 1/10/2025 through 3/4/2025 revealed that her log was marked as Activity did not occur on 22 days during that time period. Those days marked as did not occur were: 3/9/2025, 3/6/2025, 3/2/2025, 3/1/2025, 2/28/2025, 2/23/2025, 2/22/2025, 2/21/2025, 2/20/2025, 2/16//2025, 2/12/2025, 2/9/2025, 2/5/2025, 2/1/2025, 1/31/2025, 1/28/2025, 1/25/2025, 1/24/2025, 1/23/2025, 1/22/2025, 1/13/2025, and 1/10/2025. Further review revealed all of the other days are noted with at least one entry of total dependence and 4 days have entries of limited assistance. Further review of the days marked as mechanical lift having been done with total dependence revealed the majority were done in late afternoon- early evening. Residents Affected - Few Observation and interview with Resident #1 on 03/11/2025 at 10:42 a.m. revealed Resident #1 was lying in a large, oversized bed, and was unable to move her right arm and leg. Due to speech disorder which resulted from her stroke, Resident #1 was only able to say a few single words over and over, but she was able to point to what she wants/needs and could nod her head yes/no to answer basic questions. During this interview, she pointed to the overhead light, and activated her call light. CNA-B answered the call light within a few seconds and saw Resident #1 point to the overhead room light, and CNA-B asked her if she wanted the light off, Resident #1 shook her head yes, and CNA-B turned off the light. During a telephone interview with family members #1 and #2 on 03/12/2025 at 10:59 a.m., family member #1 stated that Resident #1 was not getting out of bed, and when they request she be assisted up into her wheelchair, they have been told they do not have 2 people on duty to do that. Family #2 stated the staff tell them that they get her up for lunch every day, but she was never up when the family comes to visit and noted that family visits about every other day and on weekends. Family Member #2 stated sometimes the staff will get Resident #1 up in her wheelchair for special occasions, but they always have to ask in advance. During a telephone interview with family member #3 on 03/14/2025 at 10:02 a.m. revealed she was aware Resident #1 was very overweight, and was difficult to transfer her to her wheelchair, but stated Resident #1 was left in bed way too much. Family member #3 asked how is she supposed to be active and lose weight if she never gets out of bed? Family member #3 stated she that if Resident #3 was able to be up in her wheelchair more, she would build up tolerance for it and participate in activities, go to exercises with therapy, and all of this would help her be more active, exercise more and help her lose that weight. Family member #3 stated the only time staff get Resident #1 up into her wheelchair is when they, her family, are there and request it. During interview with the Social Worker on 3/14/2025 at 9:48 a.m. the Social Worker clarified that Resident #1's BIMS score was 00, indicating severe cognitive impairment, not only due to her speech impediment, but noted that even by nodding her head, she was unable to remember the words given to her during the assessment. The Social Worker also stated that Resident #1's family has requested that Resident #1 be assisted up into her wheelchair at noon meals every day, or to get her up for at least one meal a day out of her room. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was left blank. During an interview with the Social Worker on 3/14/2025 at 9:48 a.m. the Social Worker clarified that Resident #1's BIMS score was 00, indicating severe cognitive impairment, not only due to her speech impediment, but noted that even by nodding her head, she was unable to remember the words given to her during the assessmentInterview on 3/14/2025 at 9:48 a.m. with the Social Worker 675641 Page 2 of 5 675641 03/14/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0561 Level of Harm - Minimal harm or potential for actual harm revealed that the family has requested that Resident #1 be assisted up into her wheelchair at noon meals every day, or to get her up for at least one meal a day out of her room. Observation on 03/11/2025 at 12:25 p.m. on Hall 500 revealed Resident #1 was in her room, in her bed, and was provided a lunch tray in her room. Residents Affected - Few Observation and interview with Resident #1 on 03/12/2025 at 12:26 p.m. revealed she was sitting in her bed, with her lunch tray on the bedside table in front of her eating lunch. When asked if she wanted to get up into her wheelchair and eat lunch in the dining room, she nodded affirmatively, indicating yes. When asked if she would like to get up in her wheelchair every day for lunch, she nodded affirmatively. When asked if staff get her up in her wheelchair for lunch, she shook her head negatively, indicataing no. Observation on 03/12/2025 at 1:46 p.m. of a mechanical lift transfer for Resident #1 from her bed to her wheelchair by CNA -B and CMA-E revealed privacy was provided, and proper procedure followed for the transfer. When she was initially being lifted in the sling, Resident #1 verbalized loudly and pointed to the back of her knees, indicating she felt pain there. The staff stopped the transfer, lowered her back to the bed and provided padding to the area behind her knees and when Resident #1 indicated she no longer felt pain, the transfer was resumed. Resident #1 did express some discomfort through grunts and facial expressions while being lifted in the mechanical lift sling. Observation revealed that her body was pressed together tightly with the sling, but her breathing did not appear compromised. As soon as Resident #1 was seated safely in her wheelchair and released from the sling, she smiled and indicated with head nods that she was okay, but did nod her head affirmatively when asked if the mechanical lift sling caused her discomfort. She shook her head negatively when asked if she felt fear during the mechanical lift transfer. Interview on 3/11/2025 at 10:49 a.m. with CNA-B revealed she was agency staff and has worked at this facility about 3 years and knows Resident #1 well. CNA-B stated Resident #1 does have a specially made wheelchair that they store in one of the empty rooms due to space concerns. She stated Resident #1 requires a 2-person mechanical lift, and that sometimes therapy will get her up into her wheelchair for special occasions, but not very often. For showers, she stated Resident #1 receives bed baths with 2 staff. Interview on 3/11/2025 at 11:52 a.m. with CMA-E revealed she has worked at the facility for about 3 years and works as both a CMA and a CNA. CMA-E stated that Resident #1 is not gotten out of bed into her wheelchair very often, and she has only seen her get out of bed when family are here and request it. CMA-E noted that it is difficult and takes a lot of time to transfer Resident #1, and that Resident #1 is only able to tolerate sitting up for about 30 minutes, and then wants to be transferred back to bed. CMA-E stated that Resident #1 gets bed baths only and is very cooperative with staff when they provide care to her. Interview on 3/13/2025 at 7:34 a.m. with LVN-D revealed she was a facility staff who had been at the facility about 2 months. She stated Resident #1 was able to communicate by pointing to what she wants, or pointing to where she hurts, and by answering yes/no questions with head nods. LVN-D stated Resident #1 will repeat the same 2-3 words over and over and will continue pointing and gesturing until staff can understand what she is trying to communicate. LVN-D stated Resident #1 required a mechanical lift with 2 staff assist, but also stated Resident #1 does not get out of bed very often. LVN-D stated that the last time she saw Resident #1 out of bed was for her Mammogram appointment the previous week. 675641 Page 3 of 5 675641 03/14/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the ADON on 03/12/2025 at 12:43 p.m. revealed that Resident #1 had a stroke years ago, and has gained a lot of weight. She stated Resident #1 has a specially made wheelchair to accommodate her and required use of a mechanical lift with at least 2 persons to assist. She further stated Resident #1 gets up and into her wheelchair about one time a week, for activities or meals. She stated for medical appointments Resident #1 is taken via stretcher by Ambulance. The ADON stated that they are working with the family, and her interdisciplinary team to aide in her weight loss, and noted she was recently put on a new medication to aid in weight loss. Interview with the Director of Rehabilitation on 03/13/2025 at 2:05 p.m. revealed Resident #1 was receiving physical therapy 3 times a week, and specifically was on a functional maintenance program. She stated physical therapy was working on increasing her bed mobility, for example using her left leg to help her turn over in bed. She stated Resident #1 needs a mechanical lift transfer with 2 staff. She stated she had not been notified by any staff of any concerns in using the mechanical lift to transfer Resident #1. Interview with PTA-C on 03/14/2025 at 10:45 a.m. revealed that Resident #1 received physical therapy services 3 times a week for 40- minute sessions, working on increasing her range of motion, and reaching exercises. She stated the therapy was done in her room, with Resident #1 lying in bed. She stated she has never seen Resident #1 get up in her wheelchair for her therapy sessions, but that it would be good if she could, as she felt Resident #1 could benefit from working on some of the equipment they have in the therapy room. She further stated that she has never gotten Resident #1 up in her wheelchair using the mechanical lift, because she would not feel safe doing that unless there were 3-4 staff there to help. PTA-C stated that Resident #1 was not able to tolerate being up in the wheelchair very long, and will cry because it causes her pain if she stays up too long in her wheelchair. During an interview with the Administrator, RN-F and the ADON on 03/14/2025 at 12:15 p.m., RN-F stated Resident #1 was transferred out of her bed regularly, and that this is documented in their EHR system. RN-F pulled up the ADL [Mechanical Lift] transfer log in their EHR system for January 10- March 4 2025 and provided a copy for the State Surveyor. RN-F did note there were some gaps of several days on the log, noting no mechanical lift transfers occurred on the days around 2/21/2025. The ADON stated that Resident #1 does refuse transfers at times because the transfers hurt her, but was not able to identify where these refusals are documented, Record review of facility policy titled Resident Rights revised February 2021 revealed: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence and self-determination. 675641 Page 4 of 5 675641 03/14/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for residents who eat in their rooms in one (Hall 500) of six halls observed for in-room dining services. Residents Affected - Some While passing lunch trays in hallway 500, CNA-A did not sanitize or clean her hands in between residents. This failure could place residents at risk for infection. Findings included: Observation of meal services on Hall 500 on 03/12/2025 at 12:17 p.m. revealed CNA-A was in process of distributing lunch trays to residents in their rooms on Hall 500. CNA-A was observed to check a tray card on the lunch tray, and then carry the tray to a resident in room [ROOM NUMBER]. CNA-A then returned to the rack of lunch trays, checked tray card on another lunch tray and carried that lunch tray to room [ROOM NUMBER]A, where she assisted Resident #1 with set up of her lunch tray by placing the tray on a nearby table, cleared Resident #1's bedside table of the previous meal's tray, then placed the lunch tray on her bedside table, and moved the table over Resident #1's lap. CNA-A raised the head of bed for Resident #1 by using the bed remote, and then helped set up the tray by removing plastic covers from the drink containers, and opening the utensils wrap. Without sanitizing her hands, CNA-A then went back to the rack of lunch trays and grabbed another lunch tray and brought it to room [ROOM NUMBER]. CNA- A pushed the rack of lunch trays down the hall and repeated this process for rooms [ROOM NUMBERS]. CNA-A did not wash or sanitize her hands in between delivering trays to the different residents' rooms, or before and after assisting Resident #1 with her lunch tray set-up, and touching several items in Resident #1's environment (bed remote, bedside table, previous meal tray) in process. Interview on 03/12/2025 at 12:33p.m. with CNA-A revealed she was an agency staff who had only worked at the facility about 2 months. CNA-A stated she had received training in infection control and stated that she did not sanitize her hands in between delivering each tray to different residents and helping them set up their trays, because it would dry out her hands too much. The CNA-A did not respond when asked what the result could be of not sanitizing her hands in between working with different residents, and stated she washed her hands prior to starting the meal service. During an interview with the ADON on 03/12/2025 at 12:43 p.m., the ADON stated all staff much sanitize their hands in between working with different residents, which included when passing lunch trays to different residents' rooms. The ADON stated that by not sanitizing hands in-between working with different residents, it could result in the spread of infection. Record review of facility policy titled Handwashing/Hand Hygiene dated 2001 revealed a policy statement: this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Continued review revealed: Hand hygiene is indicated: a. immediately before touching a resident . after touching a resident and .after touching a resident's environment. 675641 Page 5 of 5