Health inspection·August 28, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 08/27/2024 at 5:00 p.m. the ADM stated everybody was responsible for the placement of call lights. The ADM further stated the residents' call lights should always been within reach. The ADM stated the call lights were important for staff to know if the resident had a need or if they needed assistance. Record review of facility's Call light - Use of policy, effective date 10-2020, read Policy It is the policy of this home to ensure residents have a call light within reach that they are physically able to access . Procedure 12. Be sure call lights are placed near the resident, never on the floor or bedside stand. Event ID: Facility ID: 675656 If continuation sheet Page 2 of 14 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 08/28/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were not verbally and physically abused for 1 of 8 Residents (Resident #5) whose records were reviewed for abuse. CNA B roughly rolled Resident #5 forward in bed applied a mechanical lift sling and roughly rolled Resident #5 back towards her in bed preparing Resident #5 for a mechanical lift transfer. CNA B told Resident #5 to shut up when Resident #5 moaned and groaned. CNA B told Resident #5 Don't grab me. when Resident #5's right hand slightly touched her right shoulder due to the force used when rolling Resident #5 back towards her. CNA B then commented, Same shit every day; every day. This noncompliance was identified as past non-complinace. The non-complinace began on 08/15/2024 and ended on 08/18/2024. The facility corrected the non-complinace before the survey began. This deficient practice could affect any resident and result in emotional and physical abuse. The findings were: Review of Resident #5's face sheet, dated 8/27/24, revealed she was admitted to the facility on [DATE] with diagnoses including Malignant neoplasm of upper-inner quadrant of unspecified female breast, unspecified protein-calorie malnutrition, unspecified Dementia, Major depressive disorder, single episode, anxiety disorder, unspecified and Parkinson's disease. Review of Resident #5's MDS assessment revealed her BIMS was 0 reflective of severe cognitive impairment; had a history of physical behavioral symptoms towards others; had history of rejecting care; was totally dependent on staff for all ADL's and had hemiplegia/hemiparisis. Review of Resident #5's Care Plan, edited 8/21/24, revealed she had an ADL performance deficit and limited physical limited mobility, approaches included CNA/Hospice aides to coordinate with nurse prior to care for pain medication administration. When providing care, (bed mobility, transfers, incontinent care) requires assist x 2 d/t pain. TRANSFER: the resident requires Hoyer lift (mechanical lift) for transfers with assist x 2 staff. Review of the facility Provider Investigation Report, dated 8/19/24, revealed the incident date involving CNA B and Resident #5 took place on 8/15/24. A family member emailed the ADM at 11:15 AM on 8/15/24 alleging CNA B abused Resident #5. The family member sent AEM video footage which showed emotional and physical abuse. The ADM reported the incident to HHSC on 8/15/24 at 1:30 PM. CNA B was terminated on 8/16/24 based on the investigation findings. The ADM confirmed abuse. In-services on topics including abuse and staff burn out were provided for all staff on 8/15/24. Review of assessment for Resident #5 on 8/15/24 at 1 PM revealed Resident could not be interviewed to ask for possible psychological affects; however, she had not had any changes in her demeanor. Review of the AEM video sent to the ADM on 8/15/24 at 11:15 AM revealed CNA B roughly rolled Resident #5 forward in bed, applied a sling (mechanical lift sling) and roughly rolled Resident #5 back towards her in bed preparing Resident #5 for a mechanical lift transfer. CNA B told Resident #5 to shut up when Resident #5 moaned and groaned. CNA B told Resident #5 Don't grab me. when Resident #5's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 3 of 14 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 08/28/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm right hand slightly touched her right shoulder due to the force used when rolling Resident #5 back towards her. CNA B then commented, Same shit every day; every day. Review of the incident/accident log from May 2024 to August 2024 did not reveal any other incidents involving abuse. Residents Affected - Few Review of other reportable events from May 2024 to August 2024 did not reveal other incidents involving abuse. Review of 18 resident safe surveys, dated 8/15/24, revealed none of the residents expressed any concerns related to abuse. Review of facility Employee List, undated, revealed 66 direct care staff. Review of an in-service training titled, Employee Burnout strategies and tips dated 8/15/24, revealed 39 staff signatures. Review of an in-service training, titled, Abuse & Neglect; dated 8/15/24 revealed 27 staff signatures. Interviews with sampled 19 residents during the survey process from 8/25/24 through 8/28/24) revealed none of the residents expressed any concerns related to abuse. Observation on 08/25/24 at 10:21 AM revealed Resident #5 lying in bed, facing the wall. Further observation revealed Resident #5 was very frail; her clavicle (shoulder) bones were protruding. Resident #5 turned when called out her name but did not talk. She did not engage in conversation; did not answer any questions. Interview on 08/27/24 at 02:27 PM with the ADM revealed she received a call from Resident #5's family member. The family member reported she observed CNA B on the automated electronic monitoring system, being rough with Resident #5. The ADM stated the family member sent her a copy of the video. The ADM stated she viewed the video and commented, CNA did not treat her like a person; she treated it like a task. The ADM stated CNA B aggressively rolled Resident #5 towards the wall and then aggressively rolled her back. Her arm flung and touched CNA B's shirt and CNA B commented Don't be grabbing me. CNA B placed the (mechanical lift) sling underneath Resident #5 and left the room. The ADM stated after returning to Resident #5's room, CNA B commented It's the same shit every day. The ADM stated CNA B used the Hoyer (mechanical lift ) on her own. The ADM stated she suspended CNA B on the same date she learned about the incident, 8/15/24. The following day, 8/16/24, she called and talked with CNA B. CNA B did not acknowledge she did anything wrong except for not having a second person to operate the Hoyer (mechanical lift). She asked CNA B about using the Hoyer (mechanical lift) on her own. CNA B told her, there was not a float (alternative staff person) to help her, so she transferred Resident #5 on her own. The ADM stated there was a float (alternative staff person), but nevertheless other staff was available. If not, then CNA B should have left Resident #5 in bed until someone else was available for assistance. The ADM stated CNA B did not recognize her interactions with Resident #5 were harsh. She stated CNA B did not show any consideration for Resident #5. She stated Resident #5 was in pain all the time related to having Cancer. The ADM commented, she forgot the camera was there and that made it worse. The ADM stated she determined CNA B was not the type of employee she wanted in the facility and terminated her. The ADM stated she spoke with other residents including Resident #12 who was opinionated and hard to please. She stated Resident #12 loved CNA B. The ADM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 4 of 14 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 08/28/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm stated other residents and staff did not express any concerns. She stated CNA B did not have other performance problems that required coaching or a write up. However, the ADM stated CNA B previously worked in the MCU for years, but they pulled her out because she was showing signs of burn out. The ADM stated CNA B was being short and impatient with the residents. The ADM further stated there had not been any other confirmed allegations of abuse since this incident. Residents Affected - Few Telephone interview on 08/28/24 at 11:43 AM with CNA B revealed she had a history of depression and PTSD related to past trauma she experienced. CNA B denied remembering all the events that took place with Resident #5 and stated she did not do anything wrong. She stated at times Resident #5 tried to hit staff while providing care. CNA B stated she did not have any help and that's why I was frustrated. I don't always have help. CNA B stated she sent a mass text message to other CNAs on duty asking for help. She stated no one showed up so she transferred Resident #5 on her own using a mechanical lift. CNA B stated she knew it required two staff for safety reasons not only for the residents but for staff as well. CNA B stated Resident #5 was not able to use her left arm; did not have control due to paralysis. CNA B stated she worked in the MCU before for 9 years prior to working on her assigned hall. She stated she was moved because they told her she did not have patience with the residents. She stated staff also told her she looked like she was burned out. CNA B admitted she was burned out and was relieved when she left the MCU. CNA B again stated she had experienced past trauma; had PTSD and depression and sometimes, some days were really bad days she would become very emotional. CNA B was asked if she believed she was safe to work as a caregiver because of her condition. She stated she was if she had someone to talk to and got it out of my system, but if not, I will have a bad day. CNA B stated she did not reach out to anyone on the day in question in an effort to vent with someone. She stated she did not have any vacation days until September 2024 and had not had a vacation in one year. CNA B stated she was stressed out related to personal matters. She denied remembering making the comment it's the Same shit every day, every day. She stated she complained to co-worker's that she needed to get another job. CNA B was asked how she thought the family felt when they saw the video. She stated I know, I know. I would be angry too. I've thought about it. I am remorseful. CNA B stated she worked with Resident #5 for about 3 to 4 months. CNA B was asked what she felt sorry about and she commented she made a mistake and should have called in to work knowing I didn't feel well. I was burned out from this place; worked here for 10 years. CNA B stated, she lost her job over it. CNA B would not elaborate on exactly why she felt remorse even after being reminded there was a video of her interactions with Resident #5. Interview on 8/28/24 at 1:30 PM with Resident #5's family members revealed she and the rest of the family were satisfied with how the ADM responded and addressed their concerns related to abuse. She stated they were pleased overall with the care the Resident received and stated there had not been any other concerns related to abuse. Interview on 8/28/24 at 3 PM with the ADM revealed she did not make a police report because they usually did not do anything about the matter. She stated she thought HHSC made staff referrals to the board. The ADM stated staff assessed other residents (completed safe survey's) on 8/15/24, who CNA B worked with on the same date with no reported concerns. The ADM stated she did not remember providing CNA B time off or providing training after being moved out of the MCU related to burnout. Interview on 8/28/24 at 4 PM with the RN, Regional Nurse Consultant, revealed she was the DON at the time CNA B worked in the MCU. She stated staffing was rough at that point and there was one particular resident in the MCU who disrupted the environment. The resident was very difficult to manage. She stated she talked with other residents and staff at the time they decided to move CNA B out of the MCU. The RN, Regional Nurse Consultant, stated there were no reported concerns related to abuse or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 5 of 14 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 08/28/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few neglect. She further stated she talked with CNA B after being moved out of the MCU and CNA B stated things were getting better. The RN, Regional Nurse Consultant, stated she extended her support to CNA B as needed. The RN, Regional Nurse Consultant, stated after the most recent incident on 8/15/24, one of the clinical staff members mentioned CNA B was attending classes related to personal matters. The RN, Regional Nurse Consultant, stated she did not know exactly for what and other staff members said they did not know either. Review of a facility policy, Abuse/Reportable Events, undated, read: All residents the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents. Definitions: • Abuse: the willful infliction of injury, unreasonable confinements, intimidation, or punishment resulting in physical hard, pain or mental anguish. Irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse. • Physical Abuse: Includes hitting, slapping, pinching, and kicking. • Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of age, ability to comprehend, or disability. Each resident has the right to be free from all types of abuse. This facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident (s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 6 of 14 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 08/28/2024 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed based on the comprehensive assessment of a resident, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 Residents (Resident #2) whose records were reviewed for wounds. Residents Affected - Few Nursing staff failed to ensure treatment orders were entered into Resident #2's EHR after she was assessed with an anal fissure (a small tear in the thin, moist tissue that lines the anus according to Mayo Clinic) to ensure Resident #2 received treatment per physician's orders. This deficient practice could affect residents with new physician orders and could contribute to a decline in physical condition. The findings were: Review of Resident #2's quarterly MDS assessment, dated 7/17/24, revealed she was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Schizoaffective Disorder and Chronic Kidney Disease, Stage III. Further review revealed Resident #2's BIMS was 12 reflective of moderate cognitive disorder. Review of Resident #2's Care Plan, dated 8/25/24, revealed she had a fissure to the coccyx with onset date of 8/23/24. Further review revealed approaches included: If skin breaks down occurs, treat per MD orders, notify MD and family. Keep skin clean and dry. Use lotion on dry scaly skin. Review of progress note dated, 8/23/24 at 12:54 PM written by LVN D read, Noted a 0.7 cm fissure to coccyx. N.O. Cleanse affected area to coccyx with wound cleanser. apply zinc and LOTA. Monitor for s/s of infection and notify MD with any concerns. Review of the Twenty-four- Hour Report, dated 8/23/24, revealed Resident #2 with Fissure coccyx Zinc BID written by LVN D. Review of a physician's order, dated 8/25/24, revealed fissure to coccyx: Clean with wc and apply zinc BID until healed written by LVN E; treatment nurse. Observation and interview on 8/28/24 at 9 AM with Resident #2 revealed she was sitting in a wheelchair in her room. Resident #2 stated she had a wound and described the area between butt her cheeks and stated staff would clean it. She stated the wound opened up a few days ago. Resident #2 stated it did not hurt and it felt ok. Interview on 08/26/24 at 04:30 PM with LVN E, treatment nurse, revealed she stated LVN D obtained a physician's order for wound treatment on 8/23/24 for Resident #2 related to a fissure. LVN D left a note on her desk, and she found it on Sunday, 8/24/24. LVN E stated she entered the order on 8/24/24. However, LVN D should have entered the order or passed it on during report after receiving the order from the MD. LVN E stated she reviewed the 24- hour report and LVN D documented the N.O. She stated there was no documentation that LVN D provided treatment on Friday, 8/23/24. LVN E stated LVN F worked 6 AM to 6 PM on 8/23/24; she did not enter the order and did not provide treatment either based on the lack of documentation. LVN E stated it also looked like Resident #2 missed treatment on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 7 of 14 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 08/28/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Saturday, 8/24/24, as well. LVN E stated as part of the management team, she ran a report on Sunday, 8/25/24, when she reported to work after the Survey team entered the facility. She stated the reports would reflect any new onset diagnosis that had been charted on, any opened orders; would run the 24-hour report so she noted the N.O. on Sunday, 8/24/24, for Resident #2. LVN E stated she normally did not work weekends and it would have been Monday, 8/25/24, before she caught the new order if no one else would have caught it. Interview on 08/28/24 at 09:51 AM with LVN D revealed she worked PRN, about 2 to 3 days monthly but had been a nurse for 44 years. LVN D stated she on Friday, 8/23/24. one of the CNA's reported Resident #2 had something on her back side. The CNA had just showered Resident #2 and she assessed the area. LVN D stated she noted what looked like a scratch on her anal area/coccyx. She stated the charge nurse on duty, RN G told her to call it a fissure. LVN G instructed her to leave a note for LVN E, treatment nurse. LVN D stated she told the nurse on duty, LVN F, about the wound and the N.O. she received. She wrote the diagnosis and N.O. on the 24- hour report, she completed a treatment progress note and provided treatment on Friday, 8/23/24. After reviewing Resident #2's EHR, she commented after 44 years of being a nurse I forgot to write the order. She stated she was responsible for writing the order because she received it from the MD. She stated if she did not enter the order then Resident #2 would not get treatment as ordered because it was the weekend and no one else would find it until the following Monday when they reviewed new orders. LVN D further stated if Resident #2 did not get treatment, then her wound would get worse. LVN D stated upon assessment Resident #2 denied pain. Interview on 08/28/24 at 10:30 AM with LVN F revealed she worked on Friday, 8/23/24; she knew LVN D received a treatment order for Resident #2. She stated she did not ensure the order was entered, she stated My mind doesn't work that way. If I don't see the order, then I don't know to provide treatment. LVN F stated she worked on Saturday, 8/24/24, and did not provide treatment. She stated on Friday, 8/23/24, she had her own tasks and was focused on getting them done and did not think about Resident #2 or whether or not LVN D entered the physician's order or if she provided treatment. Interview on 08/28/24 at 10:39 AM with the DON and ADON revealed LVN D should have entered the order because she received it. However, LVN G, could have entered the order or the nurse supervisor, RN G. The DON stated it was true staff members were not responsible for completing other nursing staff members tasks; however, knowing that it was the weekend, it would be best practice to ensure the physician's order was entered. The DON stated it was also best practice that nursing staff follow the physician's orders. The DON stated the oncoming nurse would not know about the order because the PRN nurse, LVN D, left early and there was no order. However, the nurse could have looked in the 24 hour report. The DON stated they audited new orders by running reports every morning, Monday through Friday, from the previous day to ensure all tasks were completed based on anything new that came up the previous day. The DON stated they did not run reports on Saturday and Sunday and stated LVN E, treatment nurse, did not work weekends and it would have been Monday, 8/26/24, before they would have ran a report. The DON stated LVN E ran the report because she reported to work after the Survey team entered the facility and noted the N.O. for Resident #2. LVN E entered the N.O. on 8/25/24. The DON stated there was no documentation that Resident #2 received treatment on 8/23/24 or 8/25/24. She stated nursing staff had been watching the wound to ensure there were no negative outcomes; that the wound did not get bigger, that Resident #2 developed an infection, or the wound worsened in any way. The DON stated there had not been any negative outcomes. Interview on 08/28/24 at 12:59 PM LVN H revealed he worked from 6 PM to 6 AM on Friday and Saturday, 8/23/24 and 8/24/24. He stated he learned about the new treatment order for Resident #2 on Sunday, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 8 of 14 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 08/28/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm 8/24/24 when the treatment nurse, LVN E called him. However, as one of the charge nurse's, one of his responsibilities was to review the 24-hour report and he should follow up on any new orders. He stated he did not remember reviewing the 24-hour report on Friday, 8/23/24 and stated it was on him because he did not review the 24 report. LVN H stated there was no documentation Resident #2 received treatment on 8/23/24 and he stated he did not provide treatment on 8/24/24. Residents Affected - Few Interview on 08/28/24 at 5:30 PM with the DON, she again stated Resident #2 did not receive treatment on 8/24/24. She stated LVN D did not enter the physician's order into their system and LVN F, who was working Station I, and the charge nurse for Resident #2, did not provide wound treatment on 8/24/24 per physician orders. Review of facility policy, Nursing Policy and Procedure, Subject: Telephone Order Processing, effective date 10/2020, read It is the policy of this home that a telephone order will be written for orders obtained verbally from a physician or physician extender. Equipment 1. The resident's medical record. a. Send original to physician for signature. b. Send a copy to the DON/ADON or the computer for update. c. Copy will be maintained in the clinical software. Procedure 1. Obtain telephone order from physician. 2. Write telephone order on physician's order form. 3. Record date and time order was received. 4. Complete resident identification information on the telephone order and the physician's first initial and last name. 5. Sing telephone order form with your first initial, last name and title. 6. Place original and one copy in designated area. 7. Director of Nursing/Designee will check daily during the morning routine to be sure telephone orders have been written correctly, ,transcribed accurately, ,and then sent to ordering physician for signature. 8. When signed telephone orders are returned to the home the signed telephone order is adhered to the copy in the chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 9 of 14 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 08/28/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 2 of 8 Residents (Resident #5 and Resident #36) who were observed for transfers. 1. CNA B transferred Resident #5 from the bed to the wheelchair using a mechanical lift which by the resident's care plan and policy required two people for operation and transfer. 2. CNA C transferred Resident #36 from the wheelchair to the bed without the use of a gait as needed due to the resident having unsteady gait. These deficient practices could affect residents who require assistive devices during transfers and could contribute to avoidable falls. The findings were: 1. Review of Resident #5's face sheet, dated 8/27/24, revealed she was admitted to the facility on [DATE] with diagnoses including Malignant neoplasm of upper-inner quadrant of unspecified female breast; unspecified protein-calorie malnutrition; Contracture, unspecified hand, Contracture, unspecified knee and Contracture, unspecified muscle site; unspecified Dementia, Major depressive disorder, single episode, anxiety disorder, unspecified and Parkinson's disease. Review of Resident #5's MDS assessment revealed her BIMS was 0 reflective of severe cognitive impairment; had a history of physical behavioral symptoms towards others; had history of rejecting care; was totally dependent on staff for all ADL's and had hemiplegia/hemiparisis. Review of Resident #5's Care Plan, edited 8/21/24, revealed she had an ADL performance deficit and limited physical limited mobility, approaches included CNA/Hospice aides to coordinate with nurse prior to care for pain medication administration. When providing care, (bed mobility, transfers, incontinent care) requires assist x 2 d/t pain. TRANSFER: the resident requires Hoyer lift for transfers with assist x 2 staff. Observation on 08/25/24 at 10:21 AM revealed Resident #5 lying in bed, facing the wall, Further observation revealed Resident #5 was very frail; her clavicle bones were protruding. Resident #5 turned when called her name but did not talk. She did not engage in conversation. Interview on 08/27/24 at 02:27 PM with the ADM revealed she received a call from Resident #5's family member on 8/15/24. The family member reported she observed CNA B on the automated electronic monitoring system, being rough with Resident #5 prior to a transfer. The ADM stated the family member sent a copy of the video. The ADM stated she viewed the video and stated CNA B used a mechanical lift (Hoyer) on her own to transfer Resident #5 from the bed to the wheelchair. The ADM stated CNA B admitted to using the mechanical lift without the assistance of a second person claiming there was not a float available. The ADM stated there was a float, but nevertheless other Staff was available. If not, then CNA B should have left Resident #5 in bed until someone else was available for assistance. Telephone interview on 08/28/24 at 11:43 AM with CNA B revealed she stated she did not have any help and that's why I was frustrated. I don't always have help. CNA B stated she sent a mass text (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 10 of 14 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 08/28/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few message to other CNAs on duty asking for help. She stated no one showed up so she transferred Resident #5 on her own using a mechanical lift. CNA B stated she knew it required two staff for safety reasons not only for the residents but for staff as well. Review of facility policy, Mechanical Lift, effective date 10/2020, read It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Lifting a resident with a mechanical lift is always a two-person procedure. 2. Review of Resident #36's face sheet, dated 3/21/20, revealed she was admitted to the facility on [DATE] with diagnoses including Transient cerebral ischemic attack, Aphasia, other abnormalities of gait and mobility and muscle wasting and atrophy, not elsewhere classified, multiple sites, Review of Resident #36's quarterly MDS assessment, dated 7/25/24, revealed her BIMS was a 5 reflective of severe cognitive impairment and she required substantial/maximal assist when coming to standing position when sitting in a chair, wheelchair or on the side of bed. Review of Resident #36's Care Plan, edited 8/26/24, revealed she was at risk for falling related to impaired mobility, incontinent of bowel and bladder, impaired cognition, poor safety awareness, right sided weakness secondary to CVA, attempts to self transfer back to bed. Approaches included staff to reeducate resident on the use of a call light, bed in lowest position, encourage resident to ask staff for assistance with transfers and keep call light within reach at all times. Review of the incident/accident log from June 2024 to August 2024 revealed Resident #36 fell twice during August 2024. Review of an incident report dated 8/8/24 revealed Resident #36 was sitting on the floor on her bottom with legs criss-crossed directly next to the side of bed. Resident (#36) was waving at staff to come here as staff was entering the room. Resident (#36) denied having pain and motioned with her hands that slid off the bed. Upon assessment no injuries were noted. Review of an incident report dated 8/26/24 CNA notified nurse that resident had fallen. Upon entry to resident room, Nursing noted Resident sitting on buttocks at bedside, with her back to the bed. CNA stated resident was transferring from bed to wheelchair and started to sit in chair then turned back to bed and let go of chair causing her to fall on buttocks at which point resident then laid self-down. CNA states that resident did not hit her head. No complaints voiced. No signs or symptoms of pain or distress noted as this time. Observation and interview on 08/25/24 at 1:30 PM revealed Resident #36 was sitting in a wheelchair at bedside. Further observation revealed CNA C transferred Resident #36 from wheelchair to the bed without using a gait belt. Resident #36's legs were wobbly when she stood up from the wheelchair. Interview on 8/25/24 at 1:35 PM with CNA C revealed he should have used a gait belt when he transferred from the wheelchair to the bed. He stated Resident #36 could stand with assistance but was unsteady and he could lower Resident #36 down to the floor if she were going to fall to avoid serious injuries. CNA C further stated using a gait belt would also protect him from injury or he would be able to help balance Resident #36 if was off-balance. CNA C stated he left his gait belt in his backpack. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 11 of 14 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 08/28/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 8/28/24 at 5:30 PM with the DON revealed a CNA should always use a gait belt when transferring a resident especially if the resident is not steady. The gait belt was used for the safety of the resident and the staff member. The DON stated the aide could help balance a resident and prevent a fall. Review of a facility policy, Gait Belt-Correct Use of, effective date 10-2020, read 'Always use the gait belt when the resident requires hands on assistance to ambulate or transfer. Event ID: Facility ID: 675656 If continuation sheet Page 12 of 14 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 08/28/2024 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)

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 observations, record reviews and interviews, the facility failed to ensure that 21 out of 21 resident rooms (401-405, 407, 410-414 and 501-510) provided a minimum of 80 square feet of floor space per resident. Twenty-one of the two-bed resident rooms measured less than the required 80 square feet per resident. This deficient practice could affect residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these rooms. The findings were: Review of the facility Bed Classification Form 3740 dated 08/26/2024 as completed by the facility Administrator revealed, Resident Rooms 401 through 405, 407, 410 through 414, and 501 through 510 were listed as two resident bedrooms. Observation on 08/24/2024 beginning at 2:45 p.m. of the measurements of resident bedrooms using a laser measuring tool by the Life Safety Code surveyor, revealed the following measurements: room [ROOM NUMBER]: 11.75 feet x 12.6 feet = 148.5 square feet (approximately 74.25 square feet per resident). room [ROOM NUMBER]: 11,75 feet x 12.75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11.75 feet x 12.75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11.75 feet x 12.75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11,75 feet x 12,75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11.75 feet x 12.75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11.25 feet x 12.66 feet = 142.42 (approximately 71 square feet per resident). room [ROOM NUMBER]: 11.66 feet x 12.66 feet = 147.61 (approximately 73.8 square feet per resident). room [ROOM NUMBER]: 11.66 feet x 12.66 feet = 147.61 (approximately 73.8 square feet per resident). room [ROOM NUMBER]: 11.75 feet x 12.75 feet = 149.81 (approximately 74.9 square feet per resident). room [ROOM NUMBER]: 11.75 feet x 12.66 feet = 147.61 (approximately 73.8 square feet per resident). room [ROOM NUMBER]: 13.5 feet x 10.9 feet = 147.15 (approximately 73.5 square feet per resident). room [ROOM NUMBER]: 10.75 feet x 13.5 feet = 145.12 (approximately 72.5 square feet per resident). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 13 of 14 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 08/28/2024 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)

F 0912 room [ROOM NUMBER]: 10.83 feet x 13.5 feet = 145.8 (approximately 72.9 square feet per resident). Level of Harm - Potential for minimal harm room [ROOM NUMBER]: 13.5 feet x 10.9 feet = 147.15 (approximately 73.5 square feet per resident). room [ROOM NUMBER]: 13.5 feet x 10.9 feet = 147.15 (approximately 73.5 square feet per resident). Residents Affected - Some room [ROOM NUMBER]: 10.83 feet x 13.5 feet = 146.2 (approximately 73.1 square feet per resident). room [ROOM NUMBER]: 10.9 feet x 13.5 feet = 147.15 (approximately 73.5 square feet per resident). room [ROOM NUMBER]: 10.83 feet x 13.5 feet = 146.2 (approximately 73.1 square feet per resident). room [ROOM NUMBER]: 10.9 feet x 13.5 feet = 142.15 (approximately 73.5 square feet per resident). room [ROOM NUMBER]: 10.9 feet x 13.5 feet = 142.15 (approximately 73.5 square feet per resident). During an interview on 08/27/2024 at 5:00 p.m., the Administrator confirmed the identified residents' rooms were 2-person rooms and did not provide a minimum of 80 square feet of floor space per resident. The Administrator requested a room size waiver for those resident rooms and completed Form 3762 Room Size Waiver for Facilities that reflected that all justification criteria for the wavier had been met which would not adversely affect the residents living in the rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675656 If continuation sheet Page 14 of 14