Inspection·October 27, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that licensed nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 18 residents (Resident #52) reviewed for nursing competency, in that: -The facility failed to ensure LVN C was competent in medication administration skills by failing to perform pre and post treatment vital signs, observing resident while administering Handheld nebulizer treatment, and documenting that the medication was administered and completed. These failures could put residents at risk for inadequate care, result in ineffective treatment, worsening of symptoms and/or medical complications. Findings included: Record review of Resident #52's electronic medical record revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included Chronic obstructive pulmonary disease (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing, Cerebral infarction (Also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Chronic systolic congestive heart failure (Systolic heart failure is a specific type of heart failure that occurs in the heart's left ventricle.). Record review of Resident #52's Order Summary Report dated 09/13/23 revealed he was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml inhalation every four hours as needed for shortness of breath via Handheld nebulizer (HHN), with HHN tubing change every Sunday. Record review of Resident #52's TAR dated 10/01/23-10/25/23 revealed the nursing staff had not documented breathing treatments of Ipratropium-Albuterol Solution by HHN, and there was no tubing change by a nurse during this period (10/01/23-10/25/23). His Pre and post vitals were also not documented on the TAR per policy. LVN C was the nurse for the 10/25/23 night shift. In an interview 10/25/23 at 11:07 a.m., the DON stated that she has been working at the facility for three weeks. The DON stated that if medication was left in the chamber overnight, it could cause the resident to have an adverse reaction to the medication, and the resident would potentially not (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 13 Event ID: 455643 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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)