Avir At New Braunfels

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

11/24/25 at 11:45 AM with Resident #2 revealed she was lying in bed. Resident #2 stated her shower had been under construction for 2 months and 2 weeks. She stated she did not like it but commented, it is what

it is, she could not do anything about it. Resident #2 stated I'd rather have my own shower but stated she used the main shower room next door to her room. Resident #2 stated the MS told her they would repair

the uneven surface in the middle of the room that was sunk in. She stated she did not have any problems walking over it with her rolling walker and had never had any falls. She stated the stain under the vanity did not bother her. Interview on 11/24/25 at 5:00 PM with the ADM revealed the facility hired a contractor to remodel multiple showers including Resident #2's shower right before the facility was bought out. He stated

the contractor decided he wanted to negotiate for more money because it was more work than he realized.

The ADM stated the company who bought out the facility was legally pursuing the contractor but stated in

the meantime the remodeling project had been at a standstill for a couple of months. The ADM stated they secured/locked all restrooms that were under construction except for Resident #2's restroom because she was adamant she wanted access to the toilet. The ADM stated he understood the restroom was not in homelike condition and Resident #2 should not have to wait 2 months to have access to the shower. He stated he understood it was an inconvenience and at this time he was waiting for the new company to give them the go ahead to secure another contractor. Review of the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity.

1. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include

the resident's right to: a. a dignified existence. Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at New Braunfels

821 US Hwy 81 W New Braunfels, TX 78130

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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

care signed by the hospice physician. The DOR stated he talked with several hospice staff including the nurse manager for months requesting a signed plan of care to no avail. The DOR stated he had brought up

the issue during morning meetings and stated he explained why the NFSS application was denied. He stated he was not able to order a CMWC for Resident #1. He stated he spoke to a company resource person who recommended that he keep asking hospice to provide the resident's plan of care. The DOR stated he never thought about discussing the issue directly with the ADM, who was his immediate supervisor, in an attempt to have him assist with resolving the matter. Interview on 11/19/25 at 1:00 PM with

the DOR and hospice DON revealed the DON stated she had not provided a current plan of care for Resident #1 because they had been waiting for the physician's signature. The Hospice DON stated this had been on-going since at least June 2025. Interview with the DOR revealed it had actually been on-going for about 1 year as of 1/1/25. Interview on 11/20/25 at 8:30 PM with the ADM revealed he did not remember

the DOR bringing up the problem he was having in obtaining a physician signed plan of care from hospice for Resident #1. He stated he also did not remember the PASARR representative emailing him about it but stated he called hospice today and they came right over and provided a signed plan of care. The ADM stated in talking with the DOR he realized the issue had been going on for about a year. He stated it should not have taken this long to complete the NFSS and it was Resident #1 who ultimately was at a disadvantage because she was not able to utilize the CMWC to assist her with positioning. Review of the facility's policy PASARR, dated 7/29/25 read in relevant part The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 4. Care Planning: Based on

the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at New Braunfels

821 US Hwy 81 W New Braunfels, TX 78130

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, to store all drugs and biologicals under proper temperature controls in 1 of 1 central supply storage room reviewed for medication storage. The facility failed to store their over-the-counter medications (8 bottles of Acetaminophen 325 mg.) in the central supply storage room maintained within 68 to 77 degrees Fahrenheit per medication recommendations. This deficient practice could place residents at risk of the medications not being as effective as they were designed to work. The findings were:Observation and interview on 11/18/25 at 2:01 PM with CNA A in the central supply storage room revealed she was assigned as the charge person for ordering and storing medications in the central supply storage room as of 10/1/25. She stated when she started organizing the storage room, she noted it was hot in the storage room and there was no ventilation. CNA A stated they stored nursing supplies including over the counter medications, enteral feedings and med pass. A thermometer was observed hanging on a top shelf. It was not registering a reading. There was a red line all the way across to the right side into the red area which read danger. It felt very stuffy and hot in the storage room. Observation and interview on 11/18/25 at 3:10 PM with the MS and CNA A in the central supply room revealed the temperature was hot. The MS stated he talked to the ADM about it being too hot in the central supply room. the MS used a laser thermometer to take a reading, and it read 84 degrees. He stated he did not know what the regulation was but would find out. The MS stated he talked to the ADM about adding an AC unit in the back service hall where the central supply storage and laundry were located. He stated the AC unit that should be cooling the service hall did not have a thermostat attached to provide airflow in the service hall. CNA A stated she spoke with a corporate staff person about the temperature in the central supply room. She stated the corporate staff brought the ADM into the storage room while she was in the room and told him he had to get it fixed ASAP because it was too hot. Interview on 11/18/25 at 3:50 PM with the ADM revealed he talked with their previous corporate staff about the temperature in the central supply room. The ADM stated they had other issues they were also addressing at the time and then the new company bought them out about 2 months ago. He stated he had not talked to the current corporate staff about it yet. The ADM stated he knew there was a regulation for maintaining the storage area at a safe range but was not sure about the specifics. He stated if the medications were not stored within acceptable parameters, it could compromise the efficacy of

the medications, and the medications would not work effectively on the residents. The ADM was asked for a policy on storage of over-the-counter medications on. It was not provided by the end of the investigation period on 11/24/25. Observation and interview in the central supply room on 11/19/25 at 2:49 PM with the DON revealed she stated it was really hot in the storage room. She stated she talked with the ADM about it but they had not had a discussion about a plan to cool the storage room. She stated she checked the temperature requirements for the over-the-counter medications and found the bottles of Acetaminophen 325 mg. read they should be stored at temperature within 68 to 77 degrees. Fahrenheit. The DON stated storing the medication exceeding the recommended storage temperature could affect the efficacy of the medication and not effectively help the residents. Observation revealed there were 8 bottles of Acetaminophen 325 mg. on a shelf. The label on the box read Store at 20-25 degree C (68-77 degrees F).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at New Braunfels

821 US Hwy 81 W New Braunfels, TX 78130

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

knew the condition of the facility and the plan was to complete repairs and paint areas which needed painting, but it would take time. He stated at this point there were other factors that took priority. The ADM stated he understood that some of the residents might not be happy with the environmental conditions, and

they deserved better but again stated it would take time. Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards. Review of

the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence.

Event ID:

Facility ID:

If continuation sheet