Health inspection·March 21, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan which described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, to include the resident's preference and potential for future discharge; for 2 of 8 residents (Residents #43 and #84) reviewed for care plan development. 1. The facility failed to care plan Resident #43's wishes to discharge from the facility. 2. The facility failed to develop care plan interventions for Resident #84's implanted defibrillator / pacemaker and accompanying cellular monitor. These failures could place residents at risk for psychosocial and physical harm. The findings included: A record review of Resident #43' admission record dated 3/20/2025, revealed an admission date of 8/30/2024 with diagnoses which included dementia, generalized anxiety disorder, and depressive episodes. A record review of Resident #43's quarterly MDS assessment dated [DATE] revealed Resident #43 was an [AGE] year-old widowed female admitted for long term care related to a history of stroke. Resident #43 was assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. Resident #43 was assessed as literate with adequate vision, hearing, with the ability to understand others and could make herself understood. Resident #43 was assessed with nearly every day feeling down, depressed, or hopeless and Little interest or pleasure in doing things. Resident #43 was assessed with partial moderate assistance - helper does less than half the effort for oral hygiene, toileting hygiene, bathing, and dressing. Resident #43 was assessed with setup or clean up assistance - helper sets up or cleans up; Resident completes activity . for sitting to lying, sit to stand, chair bed transfer, toilet transfer shower transfer, and walking up to 150 feet. In reference to the question Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? the facility documented Resident #43 had requested only to be asked during comprehensive assessments. Further review revealed a referral to the local contact Page 1 of 13 676233 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0656 agency was not made related to Resident #43 refusal. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #43's nursing admission assessment dated [DATE] revealed no documentation for Resident #43's Discharge Planning without any goals and interventions for discharge planning. Residents Affected - Some A record review of Resident #43's care plan meeting documents dated 9/2/2024 and 3/6/2025 revealed Resident #43 attended along with the MDS nurse, and the Social Worker Assistant (SSA). Further review revealed the MDS nurse documented Resident #43's discharge election was for Resident #43 to transition to Medicaid pending LTC (long term care). Record reviews of Resident #43's care plan dated 8/31/2024 and 12/19/2024 revealed, interview Resident regarding . discharge plans. Communicate with IDT as indicated. During an interview on 3/18/2025 at 4:10 PM, Resident #43 stated she was frustrated with the lack of information regarding her discharge home. Resident #43 stated she was admitted to the facility in August 2024 for care after a hospitalization for a stroke. Resident #43 stated she has had therapy since and has improved with her ability to care for herself and wished to return home. Resident #43 stated she did have difficulty thinking and ability to recall since her stroke. Resident #43 stated no one had gotten Back to her with information for her discharge. Resident #43 stated she had a place to stay and just needed a little assistance. During an interview on 3/20/2025 at 3:20 PM, APS stated she was Resident #43's adult protective services case worker in the past. APS stated Resident #43 had a closed adult protective service case and stated Resident #43 had family who wished not to participate in Resident #43's life. APS stated Resident #43 had been living in the community and had a history of strokes with hospitalizations and was living in nursing homes due to not being able to afford safe independent living with private home health care, She has nowhere to go and no family that wants to assist her, she is not safe by herself. During an interview on 3/19/2025 at 1:45 PM, the MDS nurse stated Resident #43 had little financial means and was in the facility for long term care. During an interview on 3/20/2025 at 5:20 PM, the Administrator stated Resident #43 had no financial means, no home, and or family to assist Resident #43 to transition to the community. The administrator stated the facility had assisted Resident #43 and applied to the state Medicaid program for financial assistance which was pending approval. During a joint interview on 3/21/2024 at 5:00 PM, the Administrator and the DON stated discharge planning began upon admission and should be in the resident's care plan which would have had direct input from residents' wishes. The DON stated the risk was for inaccurate care plans and residents not receiving care and or being supported with their needs. 2. A record review of Resident #84's admission record dated 3/21/2025 revealed an admission date of 8/16/2024 with diagnoses which included presence of automatic cardiac defibrillator (a small battery-powered device placed in the chest. It detects and stops irregular heartbeats. It constantly checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heartbeat) and chronic 676233 Page 2 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some atrial fibrillation (AFib - an irregular and often very rapid heart rhythm, can lead to blood clots in the heart. Also increases the risk of stroke, heart failure and other heart-related complications.) A record review of Resident #84's quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15, which indicated intact cognition. A record review of Resident #84's physicians orders dated 3/21/2025 revealed resident had an implanted pacemaker defibrillator, ICD/Defibrillator: Left ant sic(anterior) chest: Manufacture Type: (name brand implanted) Serial# (number) Model#DTMA1D1 Procedure Date: 02/08/2023 Cardiologist & Contact Information: (name of cardiologist). A record review of Resident #84's care plan dated 3/20/2025 revealed Resident #84 had a focus for his ICD pacemaker without details for use, care, or monitoring, I have an implanted device r/t: Defibrillator Date Initiated: 08/19/2024 . I will not experience complications associated with my implanted device through my next review date. During an observation and interview on 3/19/2025 at 11:10 AM, Resident #84 was observed in his room seated in his wheelchair. Resident #84 stated he had a history of irregular heartbeats which had made him weak and limited in his lifestyle. Resident #84 stated he could no longer have endurance for simple everyday tasks like walking due to shortness of breaths. Resident #84 stated he had an implanted pacemaker in his chest which could deliver shocks to his heart if it needed it. Resident #84 stated he was aware of the devices inability to work if he encountered any strong magnates, microwaves, and or radio signals. Resident #84 stated he had a box which sent messages to the doctor and demonstrated an electronic device kept by his bedside. An observation of the device revealed a manufactures label which identified the device as a cardiac monitor for Resident #84's implanted pacemaker. Further observation revealed Resident #84 had a cellular phone. Resident #84 stated he had a cellular phone and used it seldomly. Resident #84 stated he had no information regarding his cell phone and his pacemaker. During an interview on 3/19/2025 at 11:50 AM, CNA B stated she was unaware of Resident #84's pacemaker and or monitoring for his pacemaker and suggested for information to ask the Director of Clinical Education. During an interview on 3/19/2025 at 11:54 AM, the Director of Clinical Education stated she was aware Resident #84 had a pacemaker and a monitoring device and stated her expectation was for CNAs to ensure the monitoring device was to be plugged into the electrical receptacle and kept by Resident #84's bedside. The Director of Clinical Education stated she was unaware if the care plan reflected her expectations for Resident #84's pacemaker's care. During an interview on 3/19/2025 at 11:56 AM, the MDS nurse stated she was the MDS nurse who assessed Resident #84 with an implanted pacemaker and assisted the IDT to develop a care plan for Resident #84 pacemaker. The MDS nurse stated Resident #84 care plan did not have any interventions for specific care and or directions for Resident #84 pacemaker and or monitor. During a joint interview on 3/21/2024 at 5:05 PM, the Administrator and the DON stated residents who had implanted pacemakers and monitoring devices should have specific nursing interventions for care and monitoring in the care plan. The DON stated the risk was for lack of care and monitoring for 676233 Page 3 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0656 residents' pacemakers. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #84's pacemakers' manufactures website: https://www.medtronic.com/content/dam/emanuals/crdm/CONTRIB_228434.pdf titled MRI Heart Failure Pacemaker with Defibrillation patient manual accessed 3/20/2025, revealed instructions for patients not to handle cellular phones close to the implanted device, To avoid any possible interference between mobile phones and your heart device, keep all mobile phones at least 6 inches (15 centimeters) away from your heart device. When using a mobile phone, hold it to the ear that is farthest away from your heart device. Also, do not carry a mobile phone close to your heart device, such as in a shirt pocket. Residents Affected - Some A record review of Resident #84's cardiac bedside monitor's manufactures website: https://www.medtronic.com/en-us/l/patients/treatments-therapies/remote-monitoring/mycarelink-monitor/setup-instructions.h accessed 3/20/2025 titled set up guide revealed instructions for the first time set up for the device to cellularly communicate with the cardiologists' office, Monitor setup guide Wireless devices: Information is sent automatically, usually while you sleep, after you send information manually the first time. Your monitor should be set up within 6-10 feet (2-3 meters) of where you sleep, preferably on a nightstand. The monitor should receive adequate cellular signal. Make sure your monitor is always on and plugged into a power outlet. Sending information the first time: Follow the steps above to send your first (manual) transmission. Ongoing use: Your device will automatically wake up and send your data on your scheduled transmission dates. Sometimes your clinic may ask you to send a manual transmission. If this happens, follow the steps above to send a manual transmission. A record review of the facility's Care Plan policy dated January 2023 revealed, The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Whenever there is a conflict between a resident's right and the resident's health or safety, the community has an obligation to accommodate the resident's rights and the resident's health by exploring alternatives. 676233 Page 4 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #37) reviewed for personal hygiene. Residents Affected - Few The facility failed to provide Resident #37, 4 of 20 scheduled showers between 02/03/2025 and 03/20/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #37's admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident with an initial admission date of 08/24/2023. MD J was identified as Resident #37's Primary Physician. Resident #37 had diagnosis that included acute chronic diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), cardiac arrhythmia (an abnormal heartbeat), and essential (primary) hypertension (high blood pressure). Record review of Resident #37's Quarterly MDS Assessment, signed and completed on 12/30/2024, reflected Resident #37 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #37's MDS assessment indicated that Resident #37 needed substantial/maximal assistance (helper does more than half the effort) for showering/bathing. Record review of Resident #37's Comprehensive Person-Centered Care Plan, dated as last review completed 02/14/2025, reflected interventions stating the resident had an ADL self-care performance deficit related to impaired mobility, spinal stenosis, polyarthritis, and generalized weakness with interventions such as x2 person assist on hygiene, dressing, and grooming. Record review of Resident #37's Hospice Physician Order, dated 02/04/2025, reflected, HHA will help PT bathe on Tuesdays and Thursdays, with facility nurse bathing PT on Saturday. Record review of Resident #37's Hospice Client Calendar Report, dated 03/20/2025, reflected that the hospice aide visited Resident #37 every Tuesday and Thursday since beginning on hospice on 02/02/2025, and had provided her a shower each day. Record review of Resident #37's tasks in her electronic health record reflected that the resident's shower days were Tuesday, Thursday, and Saturday. Further review revealed Resident #28 did not receive 4 of the 6 showers scheduled on Saturdays since beginning hospice care on 02/02/2025. The Saturdays in which showers were missed are as follows: 02/08/2025, 02/15/2025, 02/22/2025, and 03/15/2025. Interview on 10/21/2025 at 10:21 AM, the DON stated she was not aware Resident #37 was not receiving showers and that while it was likely she did receive a shower, they did not have documentation apart from what was provided to show that Resident #37 was provided a shower on 02/08/2025, 02/15/2025, 676233 Page 5 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0677 02/22/2025, or 03/15/2025. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy, dated revised January 2023, titled, Routine Resident Care reflected Showers, tub baths, and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preference. Shower schedule should be geared to resident preference and scheduled as such. Residents Affected - Few 676233 Page 6 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0679 Provide activities to meet all resident's needs. 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 reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 (Residents #34, #40, and #48) of 8 residents reviewed for activities. Residents Affected - Some 1. The facility failed to provide residents in the memory care unit, including Resident #40, with activities designed to meet their interests and promote physical, mental, and psychosocial well-being. 2. The facility failed to provide in-room activities for Resident #34, Resident #48 reviewed for activity interventions. This failure could place residents at risk for decline in mental acuity and increase in negative behaviors due to a lack of stimulation, boredom, and depression. The findings included: 1. Record review of Resident #40's admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE], with diagnosis of dementia, anxiety, and mood disorder. Record review of Resident #40's Quarterly MDS Assessment, signed and completed on 01/28/2025, reflected a BIMS score of 0, indicating the resident was severely cognitively impaired. Record review of Resident #40's Comprehensive Person-Centered Care Plan, dated as last review completed 03/20/2025, reflected that Resident #40 was able to participate in activities of her choice, with interventions such as, Provide me with an activity calendar, and Remind & Assist me to the planned activities as scheduled. Observation and interview on 03/18/2025 at 11:08 AM, CNA G stated that many times CNA's are left in the memory care alone and while they attempt to occupy the residents, there are too many to adequately host activities. CNA G stated that they have a new activities director and he will sometimes come and do a little thing with a ball for the residents. CNA G stated that is the only activity she has ever seen done and that it is not daily. Observation did not reveal an activities calendar available in the memory care unit. CNA G stated that activities, or even going outside, would be beneficial for residents especially in the memory care to assist with mitigating anxious behaviors. No nurse was observed in the memory care. 2. Record review of Resident #34's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #34's most recent physician's progress noted dated 3/5/25 676233 Page 7 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a chronic lung disease that permanently damages the lungs' air sacs, making it difficult to breath). Record review of Resident #34 activity participation log on 3/20/25 revealed no data regarding in-room activity participation program. Record review of Resident #48's face sheet revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Record review of Resident #48's most recent physician's progress noted dated 2/24/25 revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), encephalopathy (a broad term for any brain disease that alters brain function or structure), PVD (Peripheral Vascular Disease, a condition that affects the blood vessels outside the heart and brain, typically in the legs), respiratory failure, anemia (a condition in which the blood doesn't have enough health red blood cells and hemoglobin to carry oxygen all through the body), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), CVA (Cerebrovascular Accident (stroke), a medical condition where blood flow to the brain is disrupted), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record review of Resident #48 activity assessments and participation log revealed no data regarding in-room activity participation program. Record review of Resident #48 Care Plan dated 3/10/25 revealed no data for activity interventions addressed. In an interview on 3/20/25 at 1:15 PM, ACT stated he has not started in-room activities at this time. Stated he was recently hired two weeks ago and Administrator advises him on what to do. In an interview on 3/20/25 at 2:10 PM, ACT 2 stated that documentation for activity interventions for each resident could be found under activity assessments. In an interview on 3/21/25 at 3:00 PM, ADM stated that he is working with the new activity director to focus on community resources that will increase activity events for the facility by offering a variant of activities. Administrator stated he is ultimately responsible for ensuring the health and well-being of all residents. Observation and record review of March 2025 Activities Calendar revealed that there were no activities scheduled for residents between 03/01/2025 and 03/07/2025, with one activity scheduled on 03/08/2025. Record review of Facility Policy, dated revised 01/2023, titled, Activities Program, reflected, The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each resident. 676233 Page 8 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

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 interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 (Residents #1, #34, #37, and #79) of 16 residents reviewed for quality of care. Residents Affected - Some 1. The facility failed to take blood pressure on Resident #37 prior to providing a blood pressure medication, amlodipine, as ordered by the resident's physician. 2. Facility failed to monitor for signs and symptoms of heart failure for Residents #1, #34, and #79 while being treated with diuretic medications furosemide (Resident #1) and spironolactone (Resident #34 and #79). This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. The findings included: 1. Record review of Resident #37's admission Record, dated 03/21/2025, reflected a [AGE] year-old female resident with an initial admission date of 08/24/2023. MD J was identified as Resident #37's Primary Physician. Resident #37 had diagnosis that included acute chronic diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), cardiac arrhythmia (an abnormal heartbeat), and essential (primary) hypertension (high blood pressure). Record review of Resident #37's Quarterly MDS Assessment, signed and completed on 12/30/2024, reflected Resident #37 had a BIMS score of 11, indicating the resident was moderately cognitively impaired. Resident #37 is documented as having an active diagnosis of hypertension. Record review of Resident #37's Comprehensive Person-Centered Care Plan, dated as last review completed 02/14/2025, reflected that the resident had a diagnosis of heart disease with an intervention, dated 09/30/2022, to monitor vital signs as indicated. Record review of Resident #37's Order Audit Report, dated 03/21/2025, reflected an order for AmLODIPine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth in the evening for HTN hold if Systolic B/P<100 with an order date of 02/03/2025, ordered by MD J. Record review of Resident #37's Blood Pressure Summary Report, dated 03/20/2025, reflected the following blood pressures obtained for March of 2025: 3/9/2025 16:34 676233 Page 9 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0684 149/72 mmHg Level of Harm - Minimal harm or potential for actual harm 3/12/2025 05:00 101/45 mmHg Residents Affected - Some 3/12/2025 05:15 110/52 mmHg 3/12/2025 05:30 116/50 mmHg 3/12/2025 06:00 126/67 mmHg 3/12/2025 06:24 123/58 mmHg Record review of Resident #37's Progress Notes, dated 03/20/2025, reflected EMAR progress notes that detail Resident #37's blood pressure taken on the following dates: 03/01/2025: 134/72 mmHg 03/04/2025: 135/60 mmHg 03/06/2025: 134/71 mmHg 03/11/2025: 131/59 mmHg 03/16/2025: 120/71 mmHg Record review of Resident #37's March 2025 Medication Administration Report reflected that amlodipine Besylate Oral Tablet 5 MG was provided every day from 03/01/2025 to 03/19/2025, apart from 03/10/2025 in which Resident #37's blood pressure was too high. There are no blood pressure vitals documented on Resident #37's Medication Administration Report. Based on the combination of these record review's, it was determined that on the following dates, Resident #37 was provided amlodipine besylate without blood pressure vital signs being checked or documented in accordance with parameters set by MD J. The dates are as follows: 03/02/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/13/2025, 03/14/2025, 03/15/2025, 03/17/2025, 03/18/2025, and 03/19/2025. Therefore, between March 1, 2025, and March 19, 2025, Resident #37 was provided Amlodipine Besylate without following orders on physician parameters 10 of 19 instances in which the resident received the medication. During an interview on 03/20/2025 at 4:50 PM, the DON stated that most residents have parameters 676233 Page 10 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some related to blood pressure medication, so their blood pressure is generally at least taken once daily, or as ordered on the medication. During an interview on 03/21/2025 at 10:21 AM, the DON stated that their Medical Director, MD F, had changed the order the evening of 03/20/2025 after the surveyor brought the discrepancies to their attention, as he did not prefer residents to have parameters on blood pressure medication. The DON stated that the blood pressure vitals on the resident were likely taken as they were held one day. 2. Record review of Resident #1's face sheet revealed a [AGE] year-oldRR reveals a [AGE] year-old female admitted to this facility on 4/29/22 and readmitted on [DATE]. Record review of Resident #1's most recent physician's progress note dated 2/17/25 revealed diagnosis of chronic right sided chest pain, Afib (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic lower extremity edema (excess fluid buildup in the body's tissues), fibromyalgia, left lower extremity cellulitis (bacterial skin infection), left lower extremity hemiplegia, and heart failure. Record review of Resident #1's Quarterly MDS dated [DATE] revealed resident required set up assistance with self-feeding, moderate assistance in oral care and wheelchair mobility; maximum assistance in upper body dressing and was totally dependent in peri-care, bathing, lower body dressing, and transfers. Record review of Resident #1's physician's orders revealed an order dated 9/21/24 for Furosemide tablet 20mg (a medication used to treat fluid retention (edema) and swelling that is caused by congestive heart failure and belongs to the group of loop diuretics (water pills); Give 1 tablet by mouth one time a day related to Heart Failure. Record review of Resident #1's Care Plan problem dated 6/7/22 identifies risk for complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema due to CHF/Heart Failure. Record review of Resident #1's weight record revealed current weight March 2025 of 182.2lbs, with the following weight fluctuations: 1/6/25 175.5lbs, 2/3/25 181.7 lbs = weight loss of 6.2lbs in 1 month (3.4%) and, 10/10/24 162.9lbs, 11/4/24 173.6 lbs = weight gain of 10.7lbs in 1 month (7.2%). Record review of Resident #34's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #34's most recent physician's progress noted dated 3/5/25 revealed diagnosis CHF (Congestive Heart Failure, a chronic condition in which the heart does not pump blood as well as it should), HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a chronic lung disease that permanently damages the lungs' air sacs, making it difficult to breath). Record review of Resident #34's Quarterly MDS dated [DATE] revealed resident required set-up assistance in self-feeding; moderate assistance in bathing, upper body dressing and wheelchair mobility; maximum assistance in peri-care, lower body dressing, and bed mobility. toilet hygiene and lower body dressing. No gait. 676233 Page 11 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #34's physician's orders revealed an order dated 9/24/24 for spironolactone tablet 100mg (a medication used to treat build-up of fluid in your body caused by heart failure); Give 1 tablet by mouth one time a day related to congestive and diastolic heart failure and an order dated 9/24/24 for torsemide 20mg (a medication used to treat fluid retention and swelling that is caused by congestive heart failure and belongs to the group of loop diuretics (water pills); Give 4 tablet by mouth one time a day related to congestive and diastolic heart failure. Record review of Resident #34's care plan problem revised 5/4/24 identifies focus problem that resident has heart disease and is at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Record review of Resident #34's weight record revealed current weight March 2025 131lbs. with the following weight fluctuations: 8/1/24-12/11/24 a loss of 31.5 lbs. Record review of Resident #79's face sheet revealed a [AGE] year-old female admitted [DATE]. Record review of Resident #79's most recent physician's progress note dated 3/19/25 revealed diagnoses include CVA (stands for cardiovascular accident, commonly known as a stroke. It refers to a medical condition where blood flow to the brain is interrupted, causing brain tissue damage), dysphagia (difficulty swallowing), Afib (Atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow), DMII (Diabetes Type II (a long term condition in which the body has trouble controlling blood sugar), depression, history of breast cancer with mastectomy (surgical procedure to remove all or part of a breast), ASHD (Arteriosclerotic Heart Disease, a condition where the arteries that supply blood to the heart become narrowed or blocked due to buildup of plaque), heart failure. Record review of Resident #79's physician's orders revealed an order for spironolactone 25mg (a medication used to treat build-up of fluid in your body caused by heart failure); Give 1 tablet by mouth in the morning related to HTN (Hypertension, a condition in which the force of the blood against the artery walls is too high). Record review of Resident #79's care plan revealed dated 3/19/25 identifies focus problem that resident has heart disease and is at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Record review of Resident #79's weight record revealed current weight March 2025 143lbs with noted increased of 17lbs over 6 months and triggered 9.7% loss x 90 days and insidious weight loss x 30 days. During observation attempt of Resident #1 on 3/17/25 at 2:07 PM, resident was lying in bed with blanket. Declined further surveyor observation. During observation of Resident #34 on 3/17/24 at 1:59 PM, revealed no signs of exacerbation of congestive heart failure. During observation of Resident #79 on 3/17/25 at 2:45 PM, revealed no signs of exacerbation of heart failure. During interview on 3/20/25 at 2:15 PM, LVN D stated that she does monitor residents with heart failure or diuretic use for pitting edema, SOB, respiratory distress. Stated indications to monitor are 676233 Page 12 of 13 676233 03/21/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0684 not noted on the MAR or in the progress notes. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/20/25 at 2:40 PM, MDS Nurse stated residents on diuretics usually have weekly weights in the TAR. Residents Affected - Some During an interview on 3/20/25 at 5:55 PM, RN E stated that it is standard nursing measures to assess residents on diuretics. Stated that they do not document effectiveness of medications and chart by exception. During interview on 3/20/25 at 12:07 PM, ADON stated protocol for residents on diuretics with weight fluctuations will be re-weighed to verify weight, and verification that resident is taking the medication will be completed. Stated that residents with cardiac medical conditions and residents at risk for fluid loss due to diuretic use would be monitored. Stated that all new admission residents will be weight x 3 weeks to obtain a baseline weight and IDT members would determine additional monitoring for diuretic use. During an interview on 3/20/25 at 12:30 PM, the DON stated that Resident #1 is non-compliant with her dietary restrictions, and she believes identified weight gain is related to food intake. DON stated she would do more research on this concern. During an interview on 3/21/25 at 12:29 PM, NP C stated she believes the facility does monitor the blood pressure, weights, and edema every shift. Stated she believes the nursing assessments are done every shift and she feels good about the facility actions and assessments on the residents who receive diuretics and does not feel it is necessary to add additional criteria or orders as the nursing measures are being done. During interview on 3/21/25 at 3:15 PM, DON stated that adverse effects of not monitoring residents for the effects of diuretic use could result in delay in treatment for residents, physical and functional decline, and possible hospitalization or death. DON stated she is responsible for ensuring the nursing staff are appropriately monitoring the effects of medications to include use of diuretics according to professional standards. During an interview on 3/21/25 at 3:20 PM, Administrator stated that the nursing department is ultimately responsible for monitoring the medical status of all the residents and assessing the effects of medications. Record review of facility policy, titled, Medication Administration with a revision date of January 2024 reflected, If applicable and/or prescribed, take vital signs or tests prior to administration of the dose. Review of Quality of Care policy (revised January 2023) revealed, Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan . 676233 Page 13 of 13