Health inspection·July 31, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 (Resident #28) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure Resident #28's OOH DNR was legible and able to use in emergency situations. This failure could affect any residents who have medical records and could result in misinformation about professional care provided.Findings included: 1. Record review of Resident #28's admission Record, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated [DATE], revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's baseline care plan, dated [DATE], revealed the resident had elected DNR status. Record review of Resident #28's order summary, dated [DATE], revealed an order for DNR with a start date of [DATE], and no end date. Record review of Resident #28's OOH DNR revealed, the document was not legible. The document was dark, and this surveyor was unable to see the information. During an interview on [DATE] at 3:06 p.m. the DON stated the SW was responsible for OOH DNR paperwork. During an interview on [DATE] at 3:08 p.m. The SW stated she had not previously seen the OOH DNR in the resident's EHR. The SW stated the information on the document was not visible. The SW stated they would request a legible copy to add to the resident's EHR. The SW stated she was unsure if an emergency occurred if they would be able to use the OOH DNR. The SW stated she was unsure if this would effect the residents wish for code status in an emergency. During an interview on [DATE] at 2:04 p.m. the Administrator stated she did not believe EMS would have accepted Resident #28's OOH-DNR if there was an emergency event. The Administrator stated she did not think if affected the resident unless he had some type of event that required emergency services. The Administrator stated she did not know if it the illegible DNR honored Resident #28's wishes of a do not resuscitate order. The Administrator stated the social worker was responsible for the resident's advance directives. During a follow up interview on [DATE] at 2:17 p.m. the DON stated she was unsure if EMS would honor the Resident's OOH DNR. The DON stated the OOH DNR was not the best copy and they had obtained a better copy of the DNR since. Record review of the facility's policy titled Advance Directives, dated [DATE], stated Resident has the right to formulate advanced directives to convey decisions about end of life ahead of time. Advanced directives are honored in accordance with state law and facility policy. Advanced directives that have been completed, will be copied and uploaded into the resident's electronic health record (EHR) and the EHR will be updated to reflect whether or not the resident has executed any advanced directives . The social Page 1 of 10 675641 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0578 Level of Harm - Minimal harm or potential for actual harm service director (SSD)/ designee will complete an advanced care planning plan of care and indicate the residence choice regarding advanced directives and code status. The social worker/ designee will also ensure that: a.) Ensure that a copy of the OOH-DNR is uploaded into the EHR. Residents Affected - Few 675641 Page 2 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

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, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #5 and Resident #28) reviewed for care plans: 1. The facility failed to ensure Resident #5's comprehensive care plan was completed in a timely manner and included his PICC line (is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). 2. The facility failed to ensure Resident #28's comprehensive care plan was completed in a timely manner and included his code status. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #5's admission record, dated 7/30/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted last on 6/7/25 with diagnoses including arthritis due to other bacteria and methicillin susceptible Staphylococcus aureus infection as the cause of disease classified elsewhere. Record review of Resident #5's admission MDS assessment, dated 6/9/25, revealed Resident #5's cognition was fully intact for daily decision making. Section O revealed he had IV access. Record review of Resident #5's Comprehensive Care Plan, initiated on 6/11/25, contained focus for nutrition and code status only. Record review of Resident #5's physician orders, dated 7/30/25, revealed an order for dressing change to PICC site every 7 days and PRN every day shift every Friday, with a start date of 6/13/25, and no end date. During an observation and interview on 7/28/25 at 2:59 p.m. Resident #5 stated he had an IV he received antibiotics nightly for a leg infection through. He stated they did provide care to the IV site, and he had no issues with the IV. Resident #5 had an intact IV access with a bandage covering the IV insertion site. 2. Record review of Resident #28's admission Record, dated 07/30/25, revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated 6/25/25, revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's comprehensive care plan, initiated on 6/13/25, contained focus areas for nutrition stating the resident met criteria for severe PCM (protein calorie malnutrition) due to low body weight and was on hospice care, and the resident had a foley. Record review of Resident #28's order summary, dated 6/30/25, revealed an order for DNR with a start date of 6/12/25, and no end date. During an interview on 7/30/25 at 3:08 p.m. The SW stated she had not seen the Resident's OOH DNR in the resident EHR. The SW stated either her or MDS B were responsible for adding the code status to the resident's care plan. During an interview on 7/30/25 at 3:15 p.m. MDS B stated Resident #5 and Resident #28's comprehensive care plans were in progress and not completed. MDS B stated the facility had recently switched medical record systems and were working on in putting all resident's care plans into the new system. MDS B stated they were behind, and she was newer to the position. During an interview on 7/31/25 at 2:11 p.m. the DON stated they were trying to get everyone caught up on care plan since they switched over EHRs. The DON stated this did not affect the residents because nurses had access to the residents in MARs and TARs. The DON stated staff knew the residents and how to care for them without the care plans. Record review of the facility's policy, titled Comprehensive Care Plans, dated 3/2022, stated Policy Statement: A 675641 Page 3 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Record review of the facility's policy titled Advance Directives, dated 10/16/24, stated Resident has the right to formulate advanced directives to convey decisions about end of life ahead of time The social service director (SSD)/ designee will complete an advanced care planning plan of care and indicate the residence choice regarding advanced directives and code status. 675641 Page 4 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 4 days [PH1] reviewed for nursing services. The daily staff posting was not posted on 7/28/25. This failure could result in residents and visitors not knowing how many staff were providing services to the residents. The findings were: In an observation on 7/28/25 at 9:35 a.m., the daily staff posting was not observed in the facility lobby, at the nursing station, or the beginning of each hall. In an observation on 7/28/25 at 12:30 p.m., the daily staff posting was not observed in the facility lobby, at the nursing station, or on any of the halls in the facility. In an observation and interview on 7/28/25 at 3:55 p.m., CNA A stated she was unsure of what the daily staff posting was or where it was located. The daily staff posting could not be located throughout the nursing station area. In an observation an interview on 7/28/25 at 4:00 p.m., the ADON stated she was unsure of where the daily staff posing was located and it could not be located in the nursing station area. The HR director stated she was responsible for posting the daily staff posting and got busy and had not done it today. In an observation on 7/29/25 at 10:45 a.m., the daily staff posting was in a frame hanging on the wall across from the nursing station and was current and complete. In an interview on 7/31/25 at 4:55 p.m., the DON stated possible consequences of the daily staff posting not being posted could be that people would not know the current staffing. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers revised August 2022, indicated Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 1. Within two hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Residents Affected - Many 675641 Page 5 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #53) reviewed for pharmacy services.Resident #53's ordered daily Lyrica (pain medication) was not available for the resident from admission on [DATE] to 7/28/25. The resident missed 7 doses.This failure could result in increased pain, and a decreased quality of life. The findings were: Record review of Resident #53's face sheet dated 7/31/25 indicated the resident was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. The resident's diagnoses included metabolic encephalopathy (a condition where brain function is disrupted due to chemical imbalances in the body, often resulting from illnesses or organ dysfunction), abscess of vulva (a collection of pus that forms in the skin or tissues of the vulva, the external female genitalia), malignant neoplasm of breast (a malignant tumor that develops in breast tissue), and low back pain. Record review of Resident #53's entry MDS dated [DATE] had no BIMS or pain information. Record review of Resident #53's pain MDS interview dated 7/22/25 indicated in the past 5 days the resident had pain, her sleep was not interrupted but her daily activities were limited due to pain and the resident had a pain scale of 4 and had received as needed [PH1] [PE2] pain medications. Record review of Resident #53's care plan undated did not address pain.Record review of Resident #53's physician orders revealed an order with a start date of 7/22/25 for Lyrica oral capsule 150 mg by mouth at bedtime for pain. Record review of Resident #53's physician orders revealed an order with a start date of 7/22/25 for tramadol oral tablet 50 mg by mouth every 6 hours as needed for pain. Record review of Resident #53's EMAR for July 2025 revealed Lyrica oral capsule 150 mg by mouth at bedtime for pain was documented as not given with a 9 indicating other/see progress notes from 7/22/25 to 7/28/25. Record review of Resident #53's EMAR for July 2025 revealed the resident's pain level was documented for day shift on 7/23/25 as a 3, on 7/26/25 as a 5, 7/27/25 as a 4, and on 7/30/25 as a 3. On 7/24/25, 7/25/25, 7/28/25, and 7/29/25 was documented as 0. Documentation for night shift pain level from 7/23/25 to 7/29/25 was documented as 0. Record review of Resident #53's EMAR for July 2025 revealed tramadol 50 mg by mouth every 6 hours as needed for pain was given on the following dates: - 7/25/25 at 8:57 p.m. with a pain level of 7 and documented as effective, -7/26/25 at 9:43 p.m. with a pain level of 8 and was effective, -7/27/25 at 8:42 a.m. with a pain level of 4 and was effective, -7/27/25 at 8:54 p.m. with a pain level of 8 and was effective, -7/28/25 at 1:41 p.m. with a pain level of 9 and was effective, 7/29/25 at 10:46 a.m. with a pain level of 8 and was effective, and 7/29/25 at 5:07 p.m. with a pain level of 8 and was effective.[PE3] Record review of Resident #53's progress notes revealed a nursing note by an unknown staff dated 7/29/25 at 11:15 a.m., the resident's Lyrica pain medication had not come from the pharmacy, and it needed to be called in to the pharmacy and a message was sent to the physician. In an observation and interview on 7/31/25 at 1:55 p.m., Resident #53 was in the activity room sitting at a table, well-groomed and dressed appropriately. The resident was seated in a wheelchair at a table by herself playing bingo. The resident was sitting calmly with no fidgeting or facial mask of pain. The resident stated she was doing okay but had chronic pain. The resident stated her pain level was normal at this time and when asked for a specific pain level the resident rated it at an 8 at this time and stated her pain was chronic with her back and she had no pain to her surgical areas. The resident stated she did not have her Lyrica here at the facility for several days at first and stated she had been on Lyrica previously, but it did not matter and not having it did 675641 Page 6 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not really affect her pain levels as she was in constant pain and was used to it. The resident further stated the staff had given her the tramadol pain medication PRN and her pain was controlled as much as it could be or had been before. In an interview on 7/31/25 at 3:45 p.m., with the DON and ADON. The ADON stated she was notified on 7/29/25 the Lyrica had not arrived and she contacted the physician, as the pharmacy stated Lyrica was on back order starting on 7/21/25. The ADON stated the pharmacy told her they had notified the physician. The ADON notified the physician, and the resident received the generic for Lyrica the same day on 7/29/25. The ADON stated the facility used agency nurses and it was missed but it had been on back order. The DON and ADON both stated there were not any consequences to the resident as the lyrica takes time to work and the resident had been medicated with other pain medication. The DON stated she asked the pharmacy to send documentation the medication was on backorder and the physician was notified and the DON stated the pharmacy told her they could not do that. In an interview on 7/31/25 at 4:00 p.m., the resident's PCP stated he could not recall if the pharmacy notified him that Resident #53's Lyrica was on back order or not. The PCP stated he was aware the resident had not had it since admission but did have it currently. The PCP further stated he did not feel it would cause the resident harm as Lyrica takes 2 weeks to work and the resident had other prn pain medication. In an interview on 7/31/25 at 3:45 p.m., the DON stated there was not a facility policy specific to Resident #53 not receiving her Lyrica pain medication. 675641 Page 7 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The cooler had a package of sliced lunch meat with a lot of juice in the package that was sliced opened and not closed. The freezer had a bag of frozen sugar cookie dough that was left open. These failures could place residents that received meals and or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 7/28/2025 at 10:21AM revealed a bag of sliced lunchmeat in the cooler that was in its original package with a substantial amount of liquid from the meat, was sliced open and was placed in a food grade plastic bag with a knot that was torn open. The bag nor the package was sealed which left the sliced lunchmeat opened. A bag of sugar cookie dough was in the freezer open and not sealed.The DM said, Oh, I'll fix that right away.Observation on 7/28/2025 at 3:30PM revealed the bag of cookie dough remained in the freezer with the bag tied closed. Interview on 7/28/2025 at 3:30PM the surveyor asked the DM about the cookie dough, she said, It was used last week on Thursday, and I thought it was okay to keep it. The surveyor asked if it was safe to keep the bag of cookie dough and she said, No, because it could have freezer burn. The DM removed the bag of cookie dough and discarded it in the garbage. Interview on 7/30/2025 at 11:28AM the RD said it was important to store food properly to prevent cross contamination of food and to prevent food borne illness to the residents. She said food stored in the freezer should be closed as well to keep the taste and so it would not have the taste of freezer burn. Record review of facility policy titled, Food Receiving and Storage dated Revised November 2022 stated' Food shall be received and stored in a manner that complies with safe food handling practices Under the section titled, Refrigerated/Frozen Food Storage stated, 1. All food stored in the refrigerator and freezer are covered, labeled, and dated ( used by date). Record review of FDA titled, Are You Storing Food Safely?' dated 1/18/2023 under the section Keep foods covered stated Store refrigerated foods in covered containers or sealed storage bags. Under Freezer Facts stated, Freezer burn is a food quality issue, not a food safety issue. It can occur when food is not securely wrapped in air-tight packaging. 675641 Page 8 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #28) reviewed for hospice services, in that: The facility failed to ensure Resident #28's hospice documents including: The most recent hospice plan of care specific to each patient, hospice election form, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, and instructions on how to access the hospice's 24-hour on-call system. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #28's admission Record, dated 07/30/25, revealed a [AGE] year-old male admitted on [DATE] with diagnosis of malignant neoplasm of rectum (rectal cancer), glaucoma (damage to the optic nerve of the eye), and obstructive and reflux uropathy (urine can't flow through your ureter, bladder, or urethra due to some obstruction). Record review of Resident #28's admission MDS assessment, dated 6/25/25, revealed the resident had fully intact cognition for daily decision making. Record review of Resident #28's comprehensive care plan, initiated on 6/13/25, contained focus areas for nutrition stating the resident met criteria for severe PCM (protein calorie malnutrition) due to low body weight and was on hospice care. Record review of Resident #28's EHR revealed a document titled hospice Documents revealed a form with hospice orders dated 6/12/25 and an illegible DNR. There was no other hospice documents located in the resident's EHR. During an interview on 7/30/25 at 3:06 p.m. the DON stated the SW and her were responsible for ensuring the residents hospice documents were available at the facility. During an interview on 7/30/25 at 3:08 p.m. The SW stated she was not responsible for the hospice binder. During a follow up interview on 7/30/25 at 3:09 p.m. the DON stated she was responsible for the Residents hospice binders. The DON stated she was unsure where Resident #28's hospice binder was at but they were looking for it. During an interview on 7/30/25 at 3:20 p.m. The hospice admission nurse stated she could not say if Resident #28's hospice binder had ever been delivered to the facility however they were working on getting the binder delivered. During an interview on 7/31/25 at 2:04 p.m. the Administrator stated the DON was responsible for resident's hospice binders. During a follow up interview on 7/31/25 at 2:17 p.m. the DON stated they were unaware that Resident #28's hospice binder was not at the facility. The DON stated she did not think the missing hospice documents would affect the resident care at the facility since they already had orders in the EHR. Record review of the facility's policy titled Hospice Program, dated 7/2017, stated Policy Statement Hospice services are available to residents at the end of life. 12. Our facility has designated ___________ (Name) __________ (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family; c. Ensuring that 675641 Page 9 of 10 675641 07/31/2025 Avir at Seguin 1215 Ashby Seguin, TX 78155

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians; d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident; (4) Names and contact information for hospice personnel involved in hospice care of each resident; (5) Instructions on how to access the hospice's 24-hour on-call system; (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident. e. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. 675641 Page 10 of 10