Inspection·July 1, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some O2/oxygen was O2 sats every shift which was completed. On 07/01/25 at 12:45 PM, in an interview with Resident #1, he said during his stay at the facility, he received oxygen and never went without it. Resident #1 said he used continuous oxygen at 3 LPM due to his diagnosis of COPD. On 07/01/25 at 1:05 PM, in an interview with Resident #2, he said he used continuous oxygen at 2 LPM. Resident #2 said he had always used oxygen due to his diagnosis of COPD. Resident #2 said the nurses checked on the oxygen machine and changed his tubing. Resident #2 was not aware of any changes to his physician's orders regarding his oxygen needs. Resident #2 said he had no trouble breathing or felt sick during this stay. On 07/01/25 at 1:15 PM, an observation with Resident #2 revealed the oxygen tubing was connected and the oxygen setting was set at 2 LPM. Resident #2 sat in his wheelchair and was not in distress. Oxygen in use sign noted at door. On 07/01/25 at 1:35, in an interview with LVN C, she said she knew if a resident needed O2 because prior to admission the facility received their paperwork which indicated the use of oxygen. LVN C said another way she found out a resident would need O2 was if the office staff placed a concentrator in the room in preparation for the admission or if the resident mentioned it during the admission assessments. LVN C said she did not recall completing the admission for Resident #1. LVN C said she recalled Resident #1 used O2 but did not recall the LPM setting. LVN C said Resident #2 used O2 at 2 LPM and it was continuous. LVN C said Resident #1 and Resident #2 had to have physician's orders for the oxygen administration and the nurses ensured to follow the orders on the MAR. On 07/01/25 at 2:25 PM, in an interview with the ADON, she said the nurses handled the oxygen concentrators and tubing. The ADON said any changes or issues regarding the oxygen machines, the staff knew to report to the nurses. The ADON said the residents had to have orders for the O2 concentration level and O2 use. The ADON said the MAR showed them the order for the LPM rate, to check the tubing, change filter, and check O2 sats. On 07/01/25 at 3:45 PM, in an interview with the DON, he said when residents were admitted , the orders came in their admissions packets, the nurses input the orders in the system, called the doctor to verify orders, and the doctor agreed or changed the medications as they saw needed. The DON said if a medication such as O2 was not part of the admitting orders or once the nurse assessed and noted the resident needed oxygen, then the nurse should have called the doctor to obtain orders. The DON said if a resident used oxygen, then there was physician's orders in place. The DON said Resident #1 had an order to change O2 tubing and check/clean/replace O2 filter every week. The DON said Resident #1 should have had an order for the oxygen and he did not. The DON said as an example, the order should have read O2 at 3LPM via nasal cannula, continuous or as needed. The DON said Resident #2 had the order to check for O2 sats every shift and did not have an order for the oxygen. The DON said he reviewed the MAR for Resident #1 and Resident #2 which had no orders for the O2's LPM. The DON said the LPM was the flow rate of delivery which was different for each resident. The DON said the nurses were in-serviced on the admissions process and changes of condition. The DON said any nurse that noted a resident using oxygen without a physician's order should have called the doctor to obtain clarification or orders. The DON said Resident #1 and Resident #2 had no negative outcomes as a result of lack of orders for the oxygen administration but it was important to have orders in place so that all staff were aware and knew what flow rate of delivery the residents required. The DON said there was potential for harm to the residents depending on if they were contraindicated or maybe allergic, but Resident #1 and Resident #2 were not. The DON said the lack of orders could have resulted in hypoxia or hyperoxia but there were no indications that Resident #1 or Resident #2 were hypoxic (insufficient oxygen) or hyperoxic (excessive oxygen) during their stays. Record review of the facility's policy subject titled, Oxygen Administration, dated revised January 2023, revealed, Compliance Guidelines: A resident receives oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm therapy when there is an order by a physician. Procedure: 3. Obtain physician orders for oxygen administration. Orders should include the following:a. oxygen source to be used (concentrator, tank)b. method of delivery (cannula, mask)c. flow rate of delivery Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 3 of 3