Inspection·July 23, 2025

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few did not know what happened to the oxygen tube. She said she could not recall if the tube was given to her or not. She said one thing she knew was that CR#1 did not have his oxygen prior to leaving the facility. During an interview on [DATE] at 10:30 AM, LVN C said before sending any resident out of the facility, the nurse in charge must complete the assessment complete the form and had it witness by a second nurse before leaving regardless of means of transportation. She said there were serval in-services on assessments, documentation and ensuring that the form was filled out correctly and witnessed by two nurses. She explained that the forms were in a binder at the nurse's station and scanned into the resident's clinical records as soon as possible. During an interview with RN D on [DATE] at 11:50AM, he said before sending any resident out of the facility, he would have a charge nurse with him to assess the resident and document any special treatment and who was responsible for transportation and ensure that the RP know what to do in an emergency. He said he would document time date and what the resident left the with if on any special treatment He would make sure the RP knows what to do. He said if resident was on oxygen, he would make sure that the RP knows how to monitor the oxygen by education the RP. He said Resident on oxygen are always transported out of the facility by EMS. He said there was a form that must be completed by both nurses the are present during the transfer. He said the forms must be signed and scan to resident clinical record. In an interview with facility's DON, and Administrator on [DATE] at 12:00 PM, the DON said the resident's RP called to let the facility know that CR #1was admitted to the hospital. The Administrator said the local Hospital called to inform the facility that CR # 1 died a few days ago. She did not remember but would check her e-mails for the exact time and date. She said as soon as the local hospital explained what happened, herself and the DON started an investigation, called the State Survey Agency and started in-services. The DON said the facility started their own investigation and an in-service on abuse, neglect and exploitation. The DON said training included residents' assessment and proper documentation before transporting residents out to an appointment and outing as well as assessing all residents on Oxygen and on any special treatment. The DON and Administrator said LVN A was immediately suspended awaiting the result of the investigation. The DON said all residents on oxygen or special treatment were usually transported by ambulance to their appointment or by the facility van on regular appointments if there was no special treatment. The DON said in case of CR #1's RP chose to take him to the clinic because that was what she did before admission to the nursing home and did not allow the facility to transport CR #1 to his appointment. During a phone interview on [DATE] at 3:00 PM, CR#1's charge nurse, (LVN #A) said she sent CR #1 to the appointment on [DATE] at about 6:30 AM with his oxygen concentrator and told CR #1's RP to ensure the concentrator was plugged in as soon as they get got to the appointment office, because the concentrator was not fully charged. She said she believed what was left would be enough to get to the Clinic. She said she knew the concentrator was not charged because it was supposed to be charged overnight but CR #1's RP did not return the charger to the facility to charge the concentrator overnight. LVN A said she thought whatever was left on the concentrator would be enough for the trip since the trip was only 30 minutes from the facility. She said she did not know how fully charged the oxygen concentrator was and did not answer to how may liters of oxygen CR #1 was on at the time of departure. She said she did not recall. LVN A said she was suspended for 3 days and had training on abuse, neglect and exploitation, assessment and documentation prior to sending any resident out of the facility regardless of means of transportation. She said all transfers must be assessed, documented, and signed by two nurses. She said there were forms to be completed by both nurses before leaving the facility. During an interview with RN A (local clinic\hospital nurse) on 07/ 23/25 at 9:15 AM, she said the RP brought CR #1 to the clinic between the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 2 of 3 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hour of 7:15 AM to 7:30 AM. and immediately requested for oxygen and stated CR #1 was out of breath. RN A said CR # 1's RP said she needed an oxygen tube for CR #1. RN A said the clinic nurse immediately brought the oxygen tubes and before the nurse could start the oxygen, CR #1 collapsed. RN A said there were always supplies at the clinic and oxygen tubes were readily available and provided to CR #1. RN A said CR #1 was intubated and transported to ICU where he later died. RN A said the administration started an internal investigation. She said she had to look at the records and find out from Medical Records before providing further information. RN A did not get back prior to exit on [DATE]. During an interview with CR#1's physician on [DATE] at 3:00 PM, he said CR #1 was one of his residents at the facility, but his medical treatment was mostly done at the local Hospital and clinic. He said CR #1 had multiple medical conditions which included COPD; and a heart condition. He said he could not speculate the course of death other than he had multiple medical conditions. The facility implemented the following to remove the noncompliance:Interview with LVN B on [DATE] at 3:00PM, he said there was a form in a binder at all nurse's station that must be filled out after assessing the resident being transported out of the facility. He said complete assessment includes all vital signs, and condition. He said the form had specific information such as oxygen, How many liters of oxygen the resident was on at the time of departure, type of portable, if the order is continuous or as needed, educate the RP on the type of equipment with a returned demonstration; if equipment uses batteries or need an electric charger and to ensure all equipment are functioning well before leaving the facility. Record Reviews of in-services and training completed by the facility, which started [DATE]- and ended on [DATE], reflected. training and in-service on Abuse, neglect and exploitation, checklist with the following requirement that must be completed by charge nurse and verified by a manager before a resident could be transported out of the facility:Resident assessment and documentation before leaving the facility. The forms revealed the following process--Do we have the necessary accessories to go with a portable oxygen yes/no-Indicate whether oxygen order is continuous or as needed-continuous/PRN.-Will this resident need a portable concentrator for hospital appointment or day pass-yes/no-Oxygen portable oxygen functional and full- yes/no-Is resident and caregiver education regarding portable oxygen use completed- Yes/No-Is resident owned equipment charged and ready to use-Yes/no.-Can giver demonstrate competency of portable Oxygen Usage-Yes/no.Last in-service was dated [DATE]- Administration of oxygen therapy:-How to read oxygen on oxygen concentrator-How to connect properly with different oxygen devices. -If a resident goes out on appointment or with family: make sure resident has sufficient oxygen in cylinders, make sure oxygen cylinder is secured properly.-If a resident uses home personal portable oxygen concentrator, then make sure battery is full and adapter is attached. Record review of facility's, undated, policy on Abuse, Neglect and Exploitation undated revealed Neglect' the failure of the facility, its employee or service providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Event ID: Facility ID: 675791 If continuation sheet Page 3 of 3