Health inspection·November 8, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1of 5 residents (CR#1) reviewed for physician notification. The facility failed to notify the physician of Resident #1's continued change in condition, including low blood pressure and high pulse rate, for approximately 12 hours. After approximately 12 hours Resident #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and was placed on life-support. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: Page 1 of 12 676066 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. 676066 Page 2 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A 676066 Page 3 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify 676066 Page 4 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0580 the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. Level of Harm - Immediate jeopardy to resident health or safety The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. Residents Affected - Some FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: CR # 1 was sent to the emergency room on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, 676066 Page 5 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. 676066 Page 6 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. Residents Affected - Some The facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. The facility failed to call 911 services to transport CR#1 to a higher level of care, instead, attempted to use their non-emergency transportation to send resident to the hospital when CR #1 ' s blood pressure was extremely low and pulse extremely high. The facility failed to transfer CR #1 to the hospital in a timely manner when resident ' s vitals began to decline. The facility initially became aware of CR#1 ' s declining vitals 11/1/23 at 5:34am and 911 was called 11/2/23 at 7:00am, 24 hours after the facility was made aware of CR#1 ' s condition. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the NF on 10/26/2023. CR#1 diagnoses included the following: chronic respiratory failure with hypercapnia (occurs when the respiratory system cannot adequately remove carbon dioxide), candida esophagitis (weakened immune system), sickle-cell trait (inherited blood disorder), demyelinating disease of central nervous system (central nervous system disorder), chronic inflammatory demyelinating polyneuritis (Progressive weakness and reduced senses in the arms and legs), Congestive heart failure (A chronic condition that prevent the heart from pumping blood as well as it should). Record review of CR#1's MDS dated [DATE] did not reveal a BIMS score. Record review of CR#1's baseline care plan dated 10/26/23 and revised on 10/30/23 revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices. Record review of CR#1's Physician Orders revealed the following orders: - Start Date-10/26/23 2200-D/C Date 11/2/23 1639 HydrAlazine HCI Oral Tablet 50 MG (Hydralazine)-Give 1 tablet by mouth every 8 hours for High blood Pressure Hold for BP<110/60 or HR <60 676066 Page 7 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some - Start Date-11/01/2023 1400-D/C Date-11/01/2023 1907 revealed an order for NS via IV Perlpheral (3L) at 75cc r/t dehydration every shift for fluids - Start Date-11/01/23 2200-D/C Date 11/02/2023 1639-NS via Clysis (introducing large amount of fluids into the body) (3L) at 75cc r/t dehydration every shifter for fluids - Start Date-11/01/2023 2200 - D/C Date-11/02/2023-Sodium Chloride Intravenous 0.9% (Sodium Chloride)- Use 75 ml/hr ml/hr Intravenously every shift for dehydration until 11/3/23 23:59 3L via Clysis Record Review of CR#1's Progress Notes revealed the following: Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:34am - blood pressure 90/68 Pulse 74 Record review of vitals revealed blood pressure completed on 11/1/2023 at 1:54pm- blood pressure 86/56 Pulse 65 Record review of vitals revealed blood pressure completed on 11/1/2023 at 5:28pm -blood pressure 75/55 Pulse 120 Record review of vitals revealed blood pressure completed on 11/2/2023 at 5:20am - blood pressure 102/57 Pulse 130 Record review of vitals revealed blood pressure completed on 11/2/2023 at 7:00am - blood pressure 63/48 Pulse 136 Record review of the SBAR summary Late Entry, created by LVN A on 11/2/23 at 10:23pm effective 11/1/23 at 7:20pm on 11/1/2023 at 12:02 revealed a change in condition: Temp: T 97.9 - 11/1/2023 3:54 Route: Forehead (non-contact) Weight: W 176.8 lb - 11/2/2023 10:52 Scale: Mechanical Lift Pulse Oximetry: O2 92.0% - 11/1/2023 13:54 Method: Room Air Blood Glucose: BS 113.0 - 11/1/2023 11:23 In an interview with FM A on 11/2/2023 at 12:25pm revealed a concern with CR#1 vitals since the early morning of 11/1/2023. The concerns were based on her level of care and her current health condition. FM A stated CR#1 had not eaten or had any fluids by mouth in 4 days and was severely dehydrated. There was a concern by the RP that nursing personnel showed no urgency in attending to CR#1's medical needs. FM A was informed on 11/1/2023 at or close to 10:00am, by the SW, that the nursing staff had ordered a doppler from the pharmacy due to nursing staff having a difficult time locating a vein. It would take at least 4 hours for the doppler to arrive to the facility. After 8 hours without follow up from the social worker or nursing staff, RP A asked RN A what was the status of the doppler. RN A informed RP A that they were changing directions because the doppler had not arrived. Interview with LVN A on 11/2/23 at 1:55pm revealed received information from LVN B about 6:30am on 11/2/23. was that CR# 1 was trending low blood pressure. LVN A was given an order to do a straight 676066 Page 8 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 Level of Harm - Immediate jeopardy to resident health or safety catheter (tube inserted through a narrow opening into a body cavity)and start resident on 3 liters saline 75cc hourly until her scheduled transportation arrived between 7:00 AM and 9:00 AM this morning. However, CNA A checked CR#1's vitals on her initial rounds and immediately reported blood pressure 55 / 44 and pulse was high as it was between 136 and 140. LVN A confirmed what she was told by CNA A by taking CR#1's vitals again. This time the resident bp was 63/48 and showed signs of Tachycardia (elevated heart rate). The DON contacted and permission given to send CR#1 out 911. Residents Affected - Some Interview on 11/2/23 at 3:54pm with CNA A revealed she took CR#1 vitals at the beginning of her shift 6a-2p). She stated she took CR#1 blood pressure, and it was low, but her pulse was high and breathing through her mouth appearing to need oxygen, which none was in the vicinity. She stated she immediately reported this to LVN A. CNA A was informed, by LVN A to get CR#1 ready because she (CR#1) was going out 911. Telephone interview with LVN B on 11/2/23 at 4:14pm revealed on 11/1/23 at approximately 10:00pm they met with RN A for shift change briefing. LVN B was informed by RN A that there was a lot going on with CR#1and FM. FM's has requested a pain pump and RN A informed FM that is not a procedure they did at the facility. LVN B informed him the family wanted CR#1 transferred to a pnotes/dx?referred hospital for a G-Tube (tube placed in stomach). LVN B stated there was no clear instructions and was unsure what was really going on. LVN B was getting ready to administer CR#1's blood pressure medication. The blood pressure as 88/61 blood pressure, which was too low. No medication was given based on the orders to hold if bp was less than 110/60. Instead, he propped her legs up because she had an IV running sodium chloride at about 0.9% running at 75 milliliters' an hour. LVN B stated RN A directed him to follow-up with transportation that was reserved for CR#1 to be picked-up between 7am-9am and taken to the hospital of choice for the FM. LVN B spoke with FM around 11:00pm on 11/1/2023 with the confirmation. Also, LNV B stated he took CR#1's vitals around 5:00am on 11/2/2023. Prior to administering CR#1's blood pressure medication, the blood pressure read 106/54 and heart rate was around 120. Because the blood pressure was out of parameters of the doctors' orders, he did not administer. LVN B also stated CR#1 responded to him calling her name. Observation of CR#1 on 11/3/23 at 9:00am at hospital revealedCR#1 was highly sedated; eyes closed no distress noted and non-interviewable. Her RP was at her bedside. RP stated she was waiting on her siblings to get to the hospital as the doctor(s) wanted to have a consultation with all of the family members. Interview with ER physician on 11/3/2023 at 9:30am revealed CR#1 arrived yesterday (11/2/2023), via, ambulance and had to be placed immediately on ventilator (Breathing machine). He stated, CR#1 is in critical condition and is not going to make it. In fact, is dying. Further stated, CR#1's current diagnosis is Pneumonia, Acute Kidney Failure and Septic Shock. In a telephone interview with Facility Physician on 11/3/23 at 1:29pm- He stated he completed his rounds on 11/1/23 at 5:00am. During his assessment of CR#1 the blood pressure was 90/68 and pulse 74. An IV for fluids was ordered at that time. Later in the afternoon toward evening hours, Physician A received a telephone call and was informed that CR#1 was dehydrated, and access needed changing (change the entrance of fluid in the body). An order was completed to change access and start clysis to 676066 Page 9 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 LLA, d/t DVT in bilateral upper extremities. NS %0.9 running at 75 cc/hr via gravity. Level of Harm - Immediate jeopardy to resident health or safety Further interview with the Facility Physician stated neither he or his NP were ever notified of the changes in CR#1's vitals. Also Stated, based on CR#1's medical history when admitted into the facility, if he had known of the low blood pressure, he would have ordered CR#1 transferred to the hospital via EMS 911. Residents Affected - Some In a telephone interview with the NP on 11/3/23 at 2:04pm. it was revealed she was notified by RN A on 11/1/23 at 9:39pm that CR#1's condition had changed, and the FM had requested CR#1 be transferred, via, transportation back to the hospital. The NP stated if the FM wanted CR#1 to go to hospital then send her out. On 11/2/23 NP received a text message from LVN A that CR#1 went to the hospital, via, 911 ambulance. NP stated at no time was she informed by the nursing staff of the decrease in vitals or the increase in pulse rate. During a telephone interview with RN A on 11/3/23 at 2:39PM- revealed CR#1 was a little responsive with yes or no questions asked throughout the evening of 11/1/2023. When touched or moved CR#1 would groan as if she was in a lot of pain. During this time, RN A stated she did not call the doctor to tell of the declining blood pressure because she felt the doctor already had been notified of the low blood pressure and she was waiting for IV rehydration that was ordered from the pharmacy. RN A stated she took CR#1's blood pressure earlier in the afternoon, stated it was low, but did not notate it nor can she remember what it was. RN A took the blood pressure again and it was 75/55 and pulse 120. CR#1 was not responding verbally at this time. When asked, why she didn't call the doctor when the vitals were 75/55 and pulse 120, RN A stated she is not sure what she was wondering at the time. RN A stated the doctor should have been called. An interview with the DON on 11/3/23 at 3:37pm - revealed he was notified on 11/2/2023 by LVN A of CR#1's declining vitals and S-Bar and that they RP wanted to wait for transportation to a hospital of choice. The DON informed LVN A to use her nursing skills and if the CR#1 needed to go 911 then call 911. The DON was not notified that CR#1's vitals were declining; but notified the resident was having a change in condition on 11/1/23 at 1:00pm. Based on the CR#1 blood pressure going from 102/57 (130) to 63/48 (136) the call to 911 should have been made. During a telephone interview with the pharmacist on 11/7/2023 at 11:16am it was revealed a verbal order for CR#1 and was called in on 11/1/23 at or around 6:22pm. The prescription was filled and went out during the 8:00pm delivery. There were no other orders. Received an email from the pharmacist on 11/7/2023 at 11:45am - that revealed an email of the fax that was sent to the pharmacy for an order of Sodium Chloride Hydration (3bags). The order was called in on 11/1/23 at 1816 (6:16pm) by RN A. A Policy Review of the Significant Change in Condition revised February 2021, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. 676066 Page 10 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 Level of Harm - Immediate jeopardy to resident health or safety The following Plan of Removal submitted by the facility was accepted on 11/7/2023 at 9:31am., after multiple revisions. FACILITY'S PLAN OF REMOVAL DATED 11/06/23. Immediate action: Residents Affected - Some CR # 1 was sent to the emergency room on [DATE] via 911 services. On 11/6/2023 an ADHOC QAPI meeting was held with the Director of Nursing, Executive Director, Medical Director and Co-Medical Director. Reviewed: IJ Template, CR #1's chart, and Plan of Removal. Director of Nursing initiated in-service on 11/6/2023 with all nursing staff changes of condition. Topics included: assessing resident blood pressure, respirations, and pulse, reporting abnormal vital signs to the physician upon identification of the abnormality, reporting abnormal vital sign trends to the Physician upon identification of the abnormality, notify the Physician of delays in care to include: unable to obtain iv access and delays in pharmacy delivery, and ensuring residents are sent to the emergency room for emergent conditions (such as severe hypotension) upon identification of the emergent condition. All nursing staff will be trained before working their next shift. New hires (licensed nurses) will receive education in orientation. Licensed Nurses will not be able to work until training is completed. Training will be completed by 11/7/2023. The Director of Nursing initiated in-service with CNAs on 11/6/23 regarding vital signs. Topics included assessing the resident's blood pressure and reporting abnormal vital signs to the charge nurse immediately. All CNAs will be trained before working their next shift. New hires (CNAs) will receive education in orientation. CNAs will not be able to work until training is completed. Training will be completed by 11/7/2023. On 11/6/23 the Director of Nursing completed a 100% audit of residents' vital signs and physician orders from 11/1/23 to present. The audit included reviewing residents' vital signs for abnormalities or abnormal trends and ensuring these were communicated with the physician timely. The audit also included reviewing new physician orders from 11/1/23 to current to ensure implementation and no delays of care. No adverse findings were noted. The DON/Designee will review Point Click Care vitals report daily to audit abnormalities in residents' vitals to include blood pressure, pulse and respirations to ensure that at the sign of abnormalities physician is promptly notified. Monitoring Review of the Plan of Removal revealed each medical staff member (RN's, LVN's and CNA's) were in-serviced, between 11/6/2023 and 11/8/2023 on Urgency in the notifications when resident vitals are abnormal, any changes in resident conditions, if blood pressure and heart rate are out of the normal parameters an immediate notification to nursing and physician is required and documentation of date, time of the occurrence. Monitoring interviews on 11/7/2023 through 11/8/2023 with 39 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's) indicated they had been in-serviced on Urgency, Changes in Conditions, assessing blood pressure parameters and how to identify and who to immediately report changes to and the importance of documentation in the system immediately. During the interviews each staff member were asked to provide an example of what they felt was urgency and what they 676066 Page 11 of 12 676066 11/08/2023 Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals are too low, or the resident has a change in condition. They also indicated if necessary and they are unable to contact the RN/LVN/DON or anyone else and the need occurs they would call 911 then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated that it was imperative for them not to wait to document, but to document all occurrences. The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 11/1/23 to present and foregoing. He stated prior to the IJ he was auditing bi-weekly; however, feels it is more important to complete the audits daily. The Executive Director was notified the IJ lowered on 11/8/2023 at 11:05am and the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. 676066 Page 12 of 12