Health inspection·December 7, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few challenge of putting the wheelchair leg rest on. After repeated tries one of the care associates comes to the nurse and voices, they are unable to put the leg rest on. The nurse implements multiple repeated tries to put the leg rest on. Improper fitting and did not lock/ snap in place moving and touching residents' skin that over lays her wheelchair seating. Resident states to just place the leg rest in her lap and wheel her onto the elevator because there are a lot of people that said that they would be there to help her. The nurse states Are you sure? Resident voices yes,, There will be someone there to help me. There's a lot of people that said that they will be there to help me. Resident assisted to/ on the elevator by the nurse. As the nurse is leaving the elevator one of the caregivers are seen leaving the restroom. The nurse communicates the need for assistance, but the care giver on her way in the middle of completing meals. Nursing calls down to the first floor/ receptionist asking is there any one down there to assist Resident # 1. The resident voices that a lot of people said that they would be there to help her. Is she there? Do see her? Receptionist says I don't see her/ let me see if therapy is here. As the nurse walks to go downstairs via the elevator meeting there the resident/ family discharging/ leaving. The elevator door is opening, and Resident # 1 is there crying loudly. The nurse continues to assist resident downstairs on the elevator with part of the exiting family. There we meet OT/ PT assist and the receptionist. 20-30 minutes working with leg rest attachment/ stability. While assistance is being provided resident is making calls on her cell phone to family, 911 (police), message to a lawyer/friends voicing being left on the elevator alone. Continue care provided until complete between the nurse, OT/ PT. Resident wheeled to the Atrium/ Lobby of her desire. Communication with D.O.N. and Administration. Continued. Frequently monitored. Observation of video footage from the facility, date and time not legible revealed Resident # 1 being placed in the elevator (second floor) by LVN1. Video footage of both the first and second floor were viewed simultaneously. It appeared that Resident # 1 was placed in the elevator (second floor) and Resident # 1 remained in the elevator for approximately 7 minutes with the door closed. Visitor # 1 approached the elevator as she was leaving the facility. The elevator door opened, and Resident # 1 was sitting in the wheelchair in the elevator. The visitor sought help for Resident # 1 and Nurse 1 entered the elevator. Resident # 1, LVN1 and the visitor were in the elevator, and they went to the first floor. Staff and visitors were observed assisting Resident # 1. Observation of video footage provided by Resident # 1, undated, revealed Resident # 1 in the elevator with the door closed. Resident # 1 was observed holding the footrest from the wheelchair and Resident # 1 was in the middle of the elevator. It appeared that Resident # 1 was unable to reach the button to the elevator, therefore, Resident # 1 push the call button to retrieve to the first or second floor or call for assistance. In an interview with Resident # 1 on 12/7/2023 at 10:50 am, she stated that on 11/1/2023 (between 5pm and 5:30 pm) LVN1, had a problem putting her footrest on her wheelchair. She stated that she was supposed to be going to therapy. She stated that she told LVN1 to put the leg rest on her lap and she would get someone downstairs to put the leg rest on the wheelchair. Resident # 1 stated that she was in a larger wheelchair, and she was able to push herself while in the chair. Resident # 1 stated that she thought LVN 1 was going down with her on the elevator. She stated that LVN 1 put her in the elevator, and she pushed the button. She stated that she asked Nurse 1 not to leave her on the elevator by herself. Resident # 1 stated that the way LVN1 placed her in the elevator she could not maneuver the wheelchair and she could not reach the buttons on the elevator. Resident # 1 stated that she was on the elevator for approximately 20 minutes before someone arrived. She stated that Visitor 1 arrived at the elevator, and she stated that when the elevator opened, she scared Visitor 1 as she was having an anxiety attack. Resident # 1 stated that Visitor 1 went to the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676066 If continuation sheet Page 2 of 5 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 676066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few station and LVN 1 came to assist her. She stated that she told Resident # 1 that she did not want her to help her as she left her alone in the elevator. She stated that she, LVN 1 and Visitor 1 rode the elevator to the first floor. She stated that the Occupational Therapist and the Physical Therapist Assistant overheard her yelling, and both came to check on her. She stated that both the Occupational Therapist and the Physical Therapist Assistant helped with placing the footrest on the wheelchair. Resident # 1 stated that she called the Administrator and the Director of Nursing. She stated that the Administrator did not answer. She stated that the Director of Nursing answered, and Resident # 1 told the Director of Nursing what happened. She stated that she was upset because the Director of Nursing insisted that LVN1 provide care to her. She stated that she refused care from LVN 1 because she left her in the elevator alone. She stated that it was hot in the elevator. Resident # 1 stated that she was not injured or harmed because of being stuck in the elevator. She stated that she was scared and anxious. In an interview with the Occupational Therapist on 12/7/2023 at 1:30 pm she stated that she and the Physical Therapist Assistant was working on paperwork when she heard Resident # 1 yelling and crying. She stated that she went to see what was going on. She stated that Resident # 1 told her that LVN1 left her in the elevator unattended. She stated that Resident # 1 stated that she did not want LVN1 to assist her. She stated that Resident # 1 was holding the footrest for the wheelchair on her lap. She stated that she tried calming Resident # 1 down. She stated that Resident # 1 was in a bariatric chair. She stated that the bariatric chair is big, and it is too heavy for Resident # 1 to maneuver by herself. In an interview with LVN1 on 12/7/2023 at 2:15 pm she stated that the incident occurred on 11/1/2023 about 4:30 pm. She stated that she was having challenges putting the leg rest on Resident # 1's wheelchair. She stated that Resident #1 suggested that she take the footrest off the chair and put them on her lap. She stated that Resident # 1 asked her to roll her into the wheelchair as she wanted to go down to the first floor. She stated that Resident # 1 told her that their staff members on the first floor would assist her. LVN1 stated that she was not aware of any policy which stated a resident cannot ride the elevator alone. She stated that when Resident # 1 asked her to place her in the elevator she stated that she was accommodating the resident's request. LVN1 stated that Resident # 1 was in a larger wheelchair, however, she was able to propel by herself while using this wheelchair. LVN1 stated that she pushed the button for Resident # 1 to go down. LVN1 stated that she called the reception desk to let the staff know that Resident # 1 was coming down. LVN1 stated that the Receptionist stated that she did not see Resident # 1 and she would check to see if Resident # 1 went to the therapy department. LVN1 stated that she went to check the elevator when she was approached by Visitor 1 who informed her that Resident # 1 was left alone in the elevator. She stated that she, Resident #1 and Visitor 1 took the elevator to the first floor. She stated that Resident # 1 was yelling and crying. LVN1 stated that she attempted to calm Resident # 1 down. She stated that when they arrived the first floor staff assisted with Resident # 1. LVN1 stated that the Occupational Therapist and the Physical Therapist Assistant calmed Resident # 1 down. She stated that the Occupational Therapist and the Physical Therapist Assistant placed the footrest on Resident # 1's wheelchair. The Nurse stated that she spoke with both Physical Therapist Assistant and the Physical Therapist and both denied having an appointment with Resident # 1. LVN1 stated that Resident # 1 refused to let her complete an assessment. She stated that Resident # 1 later agreed to let the nurse complete a physical assessment. LVN1 stated that Resident # 1 was not in distress and there were no noted concerns. In an interview with the Physical Therapist Assistant on 12/7/2023 at 3:00 pm she stated that she did not know what happened on the second floor. She stated that she was completing paperwork when the Occupational Therapist asked her to assist with placing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676066 If continuation sheet Page 3 of 5 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 676066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the footrest on Resident # 1's wheelchair. She stated that Resident # 1 proceeded to tell her that Nurse 1 left her alone in the elevator. She stated that LVN1 proceeded to tell her that Resident # 1 told her that she had an appointment with the therapy department. She stated that both Resident # 1 and Nurse 1 was trying to tell their side. She stated that she was there to assist with placing the footrest on Resident # 1's wheelchair. The Physical Therapist Assistant stated that the footrest legs were not an appropriate fit for this wheelchair. She stated that they do not use this bariatric wheelchair, however, Resident # 1 insisted that she used this chair. She stated that Resident # 1 has a smaller wheelchair, but she refuses to use it. She stated she had not seen Resident # 1 self-propel with the bariatric wheelchair. The Physical Therapist Assistant stated that the situation was intense as Resident # 1 was yelling and crying. She stated that once the legs were placed on the wheelchair, she pushed Resident # 1 to the front of the building as this was the resident's request. In an interview with the Administrator on 12/7/2023 at 3:15 pm he stated that he was not on duty when the incident occurred. He stated that he missed a call from Resident # 1 on the date of the incident. He stated that Resident # 1 did speak with the Director of Nursing on the date of the incident. He stated that he and Resident # 1 discussed the incident the following day. He stated that an internal investigation was completed, and an incident was reported. He stated that his investigation included interviews with LVN1 and Resident # 1 and watching the facilities video footage. He stated that LVN1 stated that Resident # 1 wanted to go downstairs to the atrium. LVN1 had difficulty locking the footrest on Resident # 1's wheelchair. He stated that LVN1 stated that Resident # 1 requested that LVN1 place the footrest on Resident # 1 lap and Resident # 1 would get someone in the therapy department to place the footrest on the wheelchair. He stated that LVN1 admitted to wheeling Resident # 1 into the elevator and LVN1 pushed the button for Resident # 1 to go the first floor. The Administrator stated that he met with Resident # 1 who stated that LVN1 left her in the elevator alone for 20 minutes. He stated that Resident # 1 stated that she wanted to go to the first floor. He stated that Resident # 1 stated that staff had difficulty placing the footrest onto Resident # 1's wheelchair. He stated that LVN1 attempted to place the footrest onto the wheelchair but was not successful. He stated that Resident # 1 stated that she told Nurse 1 to place the footrest on Resident #1's lap and Resident # 1 would get someone in the physical therapy department to place the footrest on the wheelchair. He stated that Resident# 1 stated that LVN1 pushed her into the elevator and left her there for 20 minutes. The Administrator stated that he reviewed the facilities video footage. The video footage was of the outside of the elevator both first and second floor. He stated that the video footage revealed that Resident # 1 was placed in the elevator by Nurse 1. He stated that Resident # 1 remained in the elevator alone for 8 minutes. The Administrator stated that the visitor opened the elevator and saw Resident #1 sitting in the wheelchair in the elevator. The Administrator stated that Resident # 1 had 2 wheelchairs - a small wheelchair and a bariatric wheelchair. He stated that Resident # 1 does not like the smaller wheelchair. The Administrator stated that Resident # 1 can maneuver, by herself, in the smaller wheelchair. He stated that Resident # 1 could not maneuver alone in the larger wheelchair as the wheels are large. The Administrator stated there was no facility policy regarding resident usage of the elevators. In an interview with the Director of Nursing on 12/7/2023 at 3:45 p.m. he stated that he received a call from Resident # 1 on the date of the incident. He stated that he did not remember the date or the time. He stated that Resident # 1 called him and stated that she was left alone in the elevator by staff. He stated that the time of the call Resident # 1 did not identify which staff. He stated that he contacted LVN1 . He stated that Nurse 1 told him what happened, but LVN1 did not mention she was the person that left Resident # 1 in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676066 If continuation sheet Page 4 of 5 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 676066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Houston 2310 S Eldridge Parkway Houston, TX 77077 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 0689 elevator. He stated that he directed Nurse to complete an assessment on Resident # 1. He stated he learned the next date that LVN1 was the staff who left Resident # 1 in the elevator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676066 If continuation sheet Page 5 of 5