Health inspection·April 5, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for resident rights. The facility failed to ensure Resident #1's NP was notified when she, who required a catheter and had a history of UTIs, began experiencing signs and symptoms such as increased bladder spasms and dysuria (painful urination) from 03/13/25 - 03/21/25. This failure placed residents at risk of medical diagnoses not getting treated and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, obesity, overactive bladder, and personal history of urinary tract infections (an infection in any part of a urinary system, including kidneys, bladder, ureters, and urethra). Review of Resident #1's quarterly MDS assessment, dated 01/01/25, reflected a BIMS score of 14, indicating she had no cognitive impairment. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/10/25, reflected she required an indwelling catheter related to obstructive and reflux uropathy (blockage in urinary tract) with an intervention of monitoring for signs and symptoms of infection. Review of Resident #1's physician order, dated 01/06/25, reflected oxybutynin chloride oral tablet 2.5 MG Give 1 tablet by mouth every 4 hours as needed for bladder spasms. Review of Resident #1's MAR for, March 2025, reflected she was administered oxybutynin chloride (for bladder spasms) on 03/02/25, 03/06/25, 03/08/25, 03/10/25, 03/13/25, twice on 03/14/25, once from 03/15/25 - 03/17/25, twice from 03/18/25 - 03/32/25, and once on 03/22/25. Review of Resident #1's physician order, dated 01/06/25, reflected phenazopyridine HCl oral tablet 200 MG - Give 1 tablet by mouth every 4 hours as needed for dysuria/pain. Page 1 of 13 676233 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's MAR for, March 2025, reflected she was administered phenazopyridine HCl twice on 03/14/25, once from 03/15/25 - 03/18/25, once on 03/20/25, and twice on 03/21/25. During a telephone interview on 03/27/25 at 11:40 AM, Resident #1's NP stated if Resident #1 had been having increased bladder pain, she would have expected to be notified and for a UA to be conducted. She stated when she saw her the previous month (February 2025), she was having similar symptoms (increased pain/burning), so she ordered a UA, and she was diagnosed with a UTI. She stated she had not been notified recently of an increase in pain for Resident #1. During an interview on 03/27/25 at 12:38 PM, LVN E stated she worked with Resident #1 sometimes but not during the week before she went to the hospital. She stated Resident #1 had been having a lot more bladder spasms over the last few months. This Surveyor showed her the MAR from March (2025) and she stated it definitely did look like she had been in more pain before her hospitalization. She stated her needing an increase in pain medication could indicate an obstruction, sediment build-up, which could lead to bladder retention, which could lead to a UTI or sepsis. She stated she believed at that point, she would have requested a UA from the NP. She stated the NP should have been notified as she should be notified any time there was a change in condition. During an interview on 03/27/25 at 12:48 PM, LVN A stated she only worked one time a week, but she worked on Resident #1's hall and she was the one that had sent her to the hospital on [DATE]. She stated she did not seem to be in more pain than usual until she had a change in condition, and she called 911. This Surveyor showed her Resident #1's March (2025) MAR and she stated the doctor should have been made aware of her increased pain. She stated especially with the bladder problems Resident #1 had a history of, if she had increased pain, there could be a complication. She stated the catheter could have been plugged or she could have a UTI. She stated the NP should have been notified because if there was a complication they could order labs or be sent to the ER. She stated the NP should be notified anytime there was a change in condition. During an interview on 03/27/25 at 1:42 PM, the DON stated Resident #1 had chronic pain. She stated her expectations were that she be notified if she had been experiencing higher pain than normal or requesting in increase in pain medications. She stated she had not heard anything about an increase in pain. A negative outcome could be a missed infection or not having her pain controlled. She stated Resident #1's increase of requesting more pain medication could be an indication of a UTI. She stated she would have expected for the nursing staff to have notified the NP of the increase in pain and bladder spasms as she should be notified any time there was a difference from their baseline or a significant change. She stated a negative outcome could be a missed infection or not having their pain controlled. During an interview on 04/04/25 at 12:34 PM, Resident #1 was sitting up in her bed with her lunch tray in front of her. She stated she had recently returned from the hospital. She stated for a few days before she went to the hospital on [DATE], she was in excruciating pain. She stated she had to ask the nurses for pain medications all the time. She stated pain and bladder spasms were typical in the past when she had a UTI, but she had never felt that kind of pain before. She stated she would just lay in her bed and sob. She stated she was happy when she was sent to the hospital because she did not think she was going to make it. She stated if she had not made it, it would have been okay because at least she would not have been in pain anymore. Review of the facility's Changes in Resident Condition Policy, revised January 2023, reflected the following: 676233 Page 2 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0580 Level of Harm - Minimal harm or potential for actual harm The resident, attending physician, and resident representative or designated family member should be notified when changes in condition or certain events occur. Review of the facility's Incontinence and Catheterization Assessment and Evaluation Policy, revised January 2023, reflected the following: Residents Affected - Few The community notifies the physician of the resident's condition or changes in the resident's continence status or development of symptoms that may represent a symptomatic UTI. 676233 Page 3 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters. The facility failed to identify a change in condition or recognize symptoms of a UTI when Resident #1, who required a catheter and had a history of UTIs, began experiencing increased bladder spasms and dysuria (painful urination) from 03/13/25 - 03/21/25. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/04/25 at 1:07 PM and an IJ template was given. While the IJ was removed on 04/05/25 at 1:35 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with indwelling urinary catheters at risk of pain, renal failure, urinary tract infections, and sepsis. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, obesity, overactive bladder, and personal history of urinary tract infections (an infection in any part of a urinary system, including kidneys, bladder, ureters, and urethra). Review of Resident #1's quarterly MDS assessment, dated 01/01/25, reflected a BIMS score of 14, indicating she had no cognitive impairment. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/10/25, reflected she required an indwelling catheter related to obstructive and reflux uropathy (blockage in urinary tract) with an intervention of monitoring for signs and symptoms of infection. Review of Resident #1's physician order, dated 01/06/25, reflected oxybutynin chloride oral tablet 2.5 MG Give 1 tablet by mouth every 4 hours as needed for bladder spasms. Review of Resident #1's MAR, February 2025, reflected she was administered oxybutynin chloride on 02/01/25, 02/03/25, twice on 02/05/25, 02/10/25, and 02/11/25. Review of Resident #1's physician order, dated 02/10/25, reflected an order for a urinalysis. Review of Resident #1's UA results, reported 02/12/25, reflected she was positive for a UTI. Review of Resident #1's physician order, dated 02/13/25, reflected Amoxicillin Oral Tablet 500 MG - Give 1 tablet by mouth three times a day for UTI for five days. Review of Resident #1's MAR, March 2025, reflected she was administered oxybutynin chloride (for 676233 Page 4 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bladder spasms) on 03/02/25, 03/06/25, 03/08/25, 03/10/25, 03/13/25, twice on 03/14/25, once from 03/15/25 - 03/17/25, twice from 03/18/25 - 03/21/25, and once on 03/22/25. Review of Resident #1's physician order, dated 01/06/25, reflected phenazopyridine HCl oral tablet 200 MG - Give 1 tablet by mouth every 4 hours as needed for dysuria/pain. Review of Resident #1's MAR, March 2025, reflected she was administered phenazopyridine HCl twice on 03/14/25, once from 03/15/25 - 03/18/25, once on 03/20/25, and twice on 03/21/25. Review of Resident #1's progress note, dated 03/22/25 at 3:41 PM and documented by LVN A, reflected the following: Called to room per [FM D]. [Resident #1] very lethargic she will open eyes when name is called. O2 nasal cannula was not on [Resident #1] checked o2 sats 78. Placed nasal cannula on [Resident #1] and rechecked o2 sat fluxuating [sic] between 88 and 90 at this time. She is mouth breathing and encouraged to use her nose to breath [sic] . Review of Resident #1's progress note, dated 03/22/25 at 3:58 PM and documented by LVN A, reflected the following: [Resident #1] is not responding to verbal stimuli. She remains lethargic. O2 sats are 88 to 90. Family members her [sic] requests to go to hospital . Called for ambulance. Review of Resident #1's EMS records, dated 03/22/25, reflected yellow puss was noted to be present in her foley catheter bag. Review of Resident #1's hospital records, dated 03/22/25, reflected the following: Reason for visit: Septic Shock . Assessment/Plan: Septic shock: [Resident #1] reportedly has been off for the past 3 days and became obtunded late this afternoon at her nursing home. Was found to be tachycardic to 120, febrile to 103, tachypneic, WBC of 16, lactate of 3.66. With history of recurrent UTIs and positive urinalysis positive. [Resident #1] given total of 2 L IV fluid bolus . Given initial dose of ceftriaxone (antibiotic) in ED . UTI (Urinary Tract Infection): [Resident #1] presents with acute encephalopathy without focal deficits, able to answer her name. [Resident #1]'s urinalysis positive for leukocyte esterase . Plan: ICU . HPI 676233 Page 5 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety [FM B] said UTI and put [sic] coming out of catheter. This is an ongoing issue, has happened numerous times. Severe abdominal pain and bladder spasms, three days. Review of Resident #1's hospital discharge paperwork, dated 03/29/25, reflected her diagnosis was septic shock due to UTI and a suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen) had been surgically placed. Residents Affected - Some During a telephone interview on 03/27/25 at 11:15 AM, Resident #1's FM C stated FM D visited Resident #1 every day. She stated FM C told her Resident #1 had been complaining of increased bladder pain and had been drowsy at least three days before hospitalization (03/22/25). She stated FM D was at the facility on 03/22/25 and FM C told her it looked like Resident #1 had a stroke and asked the nurse to check on her. She stated the nurse found her to be non-responsive and she was sent to the hospital and diagnosed with septic shock and a UTI. During a telephone interview on 03/27/25 at 11:40 AM, Resident #1's NP stated if Resident #1 had been having increased bladder pain, she would have expected to be notified and for a UA to be conducted. She stated when she saw her the previous month (February 2025), she was having similar symptoms (increased pain/burning), so she ordered a UA, and she was diagnosed with a UTI. During an interview on 03/27/25 at 12:38 PM, LVN E stated she worked with Resident #1 sometimes but was not sure if she had the week before she went to the hospital. She stated Resident #1 had been having a lot more bladder spasms over the last few months. This Surveyor showed her the MAR from March (2025) and she stated it definitely did like she had been in more pain before her hospitalization. She stated her needing an increase in pain medication could indicate an obstruction, sediment build-up, which could lead to bladder retention, which could lead to a UTI or sepsis. She stated she believed at that point, the nurses should have requested a UA from the NP. During an interview on 03/27/25 at 12:48 PM, LVN A stated she only worked one time a week, but she worked on Resident #1's hall and she was the one that had sent her to the hospital on [DATE]. She stated she did seem to be in a little more pain than usual, but when she had a change in condition, and she called 911. She did not observe any puss in her drainage bag. This Surveyor showed her Resident #1's March (2025) MAR and LVN A stated the doctor should have been made aware of her increased pain. She stated especially with the bladder problems Resident #1 had a history of, if she had increased pain, there could be a complication. She stated the catheter could have been plugged or she could have a UTI. During a telephone interview on 03/27/25 at 1:03 PM, LVN F stated she worked with Resident #1 regularly (her initials were on the MAR regularly for the pain medications during the time Resident #1 was having increased pain). She stated she had been requesting more pain medication during that time, but she believed they were effective in managing her pain. She stated she did not think that would be a reason to request a UA because of her history of bladder spasms. During an interview on 03/27/25 at 1:42 PM, the DON stated Resident #1 had chronic pain. She stated her expectations were that she be notified if she had been experiencing higher pain than normal or requesting in increase in pain medications. She stated she had not heard anything about an increase in pain. A negative outcome could be a missed infection or not having her pain controlled. She stated Resident #1's increase of requesting more pain medication could be an indication of a UTI. During a telephone interview on 03/27/25 at 4:45 PM, Resident #1's FM D stated he visited her every 676233 Page 6 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some day. He stated for about four or five days or so before her hospitalization, her spasms and pain had been much worse. He stated he had mentioned to the nurses (could not give names) several times that it must be a UTI if she was having spasms as much as she was. He stated on 03/22/25 around 5:00 PM he could not get her to respond so he asked for her to be sent to the ER. He stated she was in the ICU for several days but now was back in a regular room. Observation on 04/04/25 at 11:20 AM revealed two CNAs performing catheter care on Resident #1's suprapubic catheter that had a dressing dated 04/04/25. Resident #1 expressed no pain, and the care was provided appropriately with no infection control issues. During an interview on 04/04/25 at 12:34 PM, Resident #1 was sitting up in her bed with her lunch tray in front of her. She stated she had recently returned from the hospital. She stated for a few days before she went to the hospital on [DATE], she was in excruciating pain. She stated she had to ask the nurses for pain medications all the time. She stated pain and bladder spasms were typical in the past when she had a UTI, but she had never felt that kind of pain before. She stated she would just lay in her bed and sob. She stated she was happy when she was sent to the hospital because she did not think she was going to make it. She stated if she had not made it, it would have been okay because at least she would not have been in pain anymore. Review of the facility's Quality of Care Policy, revised January 2023, reflected the following: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. 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, the resident's choices. . A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections . Review of the facility's Incontinence and Catheterization Assessment and Evaluation Policy, revised January 2023, reflected the following: The community's protocols include policies and procedures that monitor the risk, prevention, and detection of urinary tract infections. The community notifies the physician of the resident's condition or changes in the resident's continence status or development of symptoms that may represent a symptomatic UTI. Review of an online article from Web MD entitled Bladder Spasms, dated 08/13/24, reflected the following: A bladder spasm, or detrusor contraction, occurs when the bladder muscle squeezes suddenly without warning, causing an urgent need to release urine . People who have had such spasms describe them as a cramping pain and sometimes as a burning 676233 Page 7 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety sensation. Some women with severe bladder spasms compared the muscle contractions to severe menstrual cramps and even labor pains experienced during childbirth. However, you are more likely to have bladder spasms with urine leakage if you: Are elderly or have a urinary tract infection. Residents Affected - Some Some common causes of bladder spasms are: Urinary tract infection (UTI): Bladder pain and burning are a common symptom of a UTI. The ADM and DON were notified on 04/04/25 at 1:07 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/05/25 at 11:30 AM:

F690 - The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. Date: 4-4-25 Corrective Action: Resident was being treated for a pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms. Was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment. Regional Nurse provided in-service to DNS/Admin/Admin in- training /ADNS regarding the following areas: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 3. Notifying medical provider of the change in condition (increased pain). 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 676233 Page 8 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Comprehension of the training was verified through return demonstration and/or follow up questioning. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director on _4/4/2025____ to review plan of removal / immediate corrective action plan implemented. Date Completed: 4/4/2025 Risk Identification: All residents who have experienced a significant change in condition may be at risk. Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents; to include but not limited to residents with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms (s/s) of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place. This includes residents with bladder and bowel issues. Outcome: Change in condition on 4/4/25 on 2 residents :outcome: MD and family notified. We were provided with new orders that were implemented. Date Completed: 4/4/2025 Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place. Outcome: There were no negative outcomes identified. 676233 Page 9 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Date Completed: Level of Harm - Immediate jeopardy to resident health or safety Systematic Changes: Residents Affected - Some Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift: Comprehension verified through follow up questions. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the significant change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the E.H.R. 3. Adhering to physician's orders and recommendations. 4. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nursing shift change report process. 5. Documentation of the resident's status and delivery of care provided according to the plan of care. 6. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 7. Nurses will conduct on-going monitoring of the resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 8. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Abuse & Neglect (ANE)- Identifying Prevention and Reporting 11. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 676233 Page 10 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 12. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 13. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. Director of Nursing / Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) -Nurses will be in serviced prior to working their next shift. DNS/ Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires. Monitoring: Director of Nursing / Assist. Director of Nursing will review nursing 24hr reports, progress notes and SBARS/change in condition and abnormal labs during the morning clinical review meeting (5-7 days per week) and to ensure that appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any Signs and symptoms (s/s) of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random interviews with the nursing team members to identify competency/comprehension of the following: Identifying signs and symptoms (s/s) of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of 676233 Page 11 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The facility will conduct a monthly Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the Electronic Health Record (E.H.R.) Findings of audits and status of compliance will be reviewed to the Administrator and the Quality Assurance Performance Improvement (QAPI) committee during the monthly meetings for the next 2 months. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The Surveyor monitored the POR on 04/05/25 as followed: Observations were made on 04/05/25 from 1:04 PM - 1:10 PM of three residents' catheter tubing and bags. All three had clear drainage with no sediment noted. During interviews on 04/05/25 from 11:32 AM - 1:28 PM, three RNs, three LVNs, one MA, and five CNAs from different shifts all stated they were in-serviced before working their shift on catheter care, communication during shifts, change in conditions, and signs and symptoms of a UTI. All stated a change in condition could be increased pain, altered mental status, or anything that is out of the resident's baseline. All staff stated that any change in condition should be relayed to the NP because it could indicate a bigger issue that could be occurring that needed to be addressed. They all gave signs and symptoms of a UTI such as altered mental status, burning during urination, dark urine, or increased pain. The aides and MA stated if they noticed any of those signs and symptoms, they would notify a nurse immediately. All stated a negative outcome of not getting orders for a suspected UTI could be sepsis or hospitalization. The nurses stated during shift changes, instances of new skin integrity issues, new orders, or any change in condition with residents should be communicated to the oncoming nurse. During an interview on 04/05/25 at 12:20 PM, the ADM stated he was in-serviced by the RNC and was aware of the process for ensuring changes in conditions were identified and relayed to the MD/NP. He stated all staff were being in-serviced before working their shifts. Review of the facility's Ad Hoc Meeting agenda, dated 04/04/25, reflected the ADM, MD, DON, and AIT were in attendance. Review of an in-service conducted by the RNC, dated 04/04/25 reflected the ADM, DON, and ADON were in-serviced on the following: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 676233 Page 12 of 13 676233 04/05/2025 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0690 3. Notifying medical provider of the change in condition (increased pain). Level of Harm - Immediate jeopardy to resident health or safety 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. Residents Affected - Some 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Review of and in-service entitled Bowel and Bladder, dated 04/04/25 - 04/05/25 and conducted by the ADM and DON, reflected all nursing staff were in-serviced on identifying bowel and bladder issues and recognizing changes in residents - increased use of PRN pain medications or increased pain with urination, and notifying the NP of those changes. Review of and in-service entitled Peri Care/Catheter Care dated 04/04/25 - 04/05/25 and conducted by the DON, reflected all nursing staff were in-serviced on the peri care audit tool and peri care steps to decrease the risk of infection. Review of assessments, dated 04/04/25, reflected all residents were assessed for pain, discomfort, or a change in condition by the DON and ADON. Two residents were determined to have a change in condition, the MD was notified, and new orders were put in place. Review of the facility's Monitoring Tool to review the 24-hour report, progress notes, SBAR/CIC, and labs daily, on 04/05/25, reflected it had been signed off as completed and they were in compliance on 04/04/25 and 04/05/25. The ADM and DON were notified on 04/05/25 1:35 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 676233 Page 13 of 13