Inspection·September 11, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 notify local authorities of a suspicious injury for 1 of 1 resident reviewed for injuries of unknown origin in that: Residents Affected - Few Resident #1 had an injury of unknown origin The facility failed to implement their policy by not reporting suspicions of abuse for a resident with injuries of unknown source. This failure could place residents at risk for potential criminal activity without consequences The findings included: A record review of Resident #31's face sheet dated 08/30/21 revealed an original admission date of 08/30/21 with diagnoses including COPD, Respiratory failure with hypoxia, emphysema, anxiety, immunodeficiency, heart failure, falls, muscle wasting and weakness, and osteoporosis. A record review of Resident #1's MDS dated [DATE] documented a BIMS of 12, indicating moderate cognitive impairment. A record review of Resident #1's care plan dated 08/31/21 documented the risk for bruising related to the use of anticoagulants with an initiation date of 09/02/23. Resident #1 had a risk for falls related to a history of falls created on 08/31/21. Resident #1 had a terminal condition and was placed on hospice care on with an initiation date of 08/27/21. A record review of the facility provider investigation summary and conclusion dated 09/08/23 revealed the morning of 09/02/23 Resident #1 was interviewed and could not recall how the raised area to her head and discoloration occurred. Resident #1 denied being struck on the head or any additional falls. Resident #1 was on Plavix & aspirin and the size of the discoloration could have been exacerbated as a result of the anticoagulant properties of these medications. Resident #1 also had episodes of confusion due to chronic respiratory failure, COPD, and emphysema which contribute to low oxygen saturation levels, along with compliance with oxygen use per nasal cannula. The facility was unable to definitively determine the cause of the discoloration of Resident #1's arm/eye/raised area to the forehead but Resident #1 likely hit her head on the enabler bar that was recently attached to her bed by hospice and subsequently removed by hospice for a smaller one. A record review of the nurse's notes dated 03/06/23 to 09/07/23 documented that Resident #1 had multiple falls due to self-transfers. (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 2 Event ID: 675850 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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)