Health inspection·June 16, 2023

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have resident rooms that measured at least 80 square feet per resident in multiple resident bedrooms for 19 of 26 resident rooms (Rooms 401-405, 407, 410-414, and 501-508) reviewed for square footage. Resident rooms 401-405, 407, 410-414, and 501-508 measured less than the required 80 square feet per resident. This failure could affect residents negatively by restricting the amount of room the residents had for needed resident care equipment, personal furnishings, and personal belongings, and could result in feelings of frustration, confined space, and a decreased quality of life. The findings were: In an interview on 6/16/23 at 9:25 a.m. the Administrator stated she wanted to continue the room waiver for all rooms not meeting the square footage requirement. Record review of the Bed Classification form 3740 signed by the Administrator on 6/13/23 revealed rooms 401, 402, 403, 404, 405, 407, 410, 411, 412, 413, 414, 501, 502, 503, 504, 505, 506, 507, and 508 were all certified rooms for two beds each. Record review of the current resident roster dated 6/13/23 revealed the rooms that did not meet double occupancy room size and were currently being used as double occupancy rooms were 401, 410, and 501-508. Observation and interview on 6/16/23 at 11:30am 12:15 p.m. with the Administrator revealed rooms 401, 402, 403, 404, 405, 407, 410, 411, 412, 413, 414, 501, 502, 503, 504, 505, 506, 507, and 508 measurements were as follows: room [ROOM NUMBER]: 12 feet 9 inches x 11 feet 9 inches = 150 (approximately 75 square feet per resident). room [ROOM NUMBER]: 12 feet 9 inches x 11 feet 9 inches = 150 (approximately 75 square feet per resident). room [ROOM NUMBER]: 12 feet 9 inches x 11 feet 9 inches = 150 (approximately 75 square feet per resident). (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 2 Event ID: 675656 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 675656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Walnut Springs 1637 N King St 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)