Health inspection·October 26, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident had an environment that was free from accident hazards for 3 of 7 residents (Resident #13, #27 and #32) reviewed for accidents, hazards, and supervision, in that: CNA I failed to safely transfer Resident #27 with 2 people and CNA I used a Hoyer lift to transfer Resident #27 from her bed to a wheelchair by herself and Resident #27 slid out of the sling to the floor. Hazardous chemicals were not kept (alcohol rub and nail polish remover observed on bedside tables) locked away from Resident#13 and Resident #32. These failures could affect the residents by placing the residents at risk for injury. Findings included: 1. Record review of a Face Sheet dated 10/25/2022 for Resident #27 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of encephalopathy (brain damage), anemia (low iron in the blood), age related osteoporosis (thin, brittle bones), Type 2 diabetes, and dementia (change in memory). Record Review of a Care Plan dated 8/12/2022 for Resident #27 indicated Resident has a self-care deficit needing extensive to total care in bed mobility, transfer with Hoyer lift x2 staff, and ADL needs of dressing, bath, hygiene, incontinent care, and mobility using a wheelchair staff propelled. She has history of falling not in last 90 days with potential for future falls related to mobility deficit, cognitive loss. 10/11/2022 slid out of Hoyer sling. An approach education provided to staff to ensure proper positioning in Hoyer sling and the use of 2 staff members for all transfers with lift. Staff assist with all transfers using Hoyer lift x2 staff up to wheelchair as tolerated. Record review of a Quarterly MDS dated [DATE] indicated Resident #27 had severe impairment in thinking with a BIMS score of 1. She was totally dependent with transfers and 2-person physical assist. Record review of a Fall/Incident Log dated October 2022 indicated Resident #27 had a witnessed fall on 10/11/2022 at 5:11 PM in the resident's room and was sent to the ER. Record review of a nurse progress note dated 10/11/2022 at 5:43 PM by RN J indicated, .Resident #27 had a fall from a mechanical lift while agency CNA I was trying to transfer her from bed to a Page 1 of 21 676166 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0689 Level of Harm - Minimal harm or potential for actual harm wheelchair post shower. CNA I stepped out of the room and asked a medication aide for help. Medication aide looked for nurse in another resident's room to inform of situation. Resident #27 was lying on the floor on her left side upon nurse arrival. CNA I said she slipped out of Hoyer. RN J began speaking to Resident #27 in Spanish, asking where she felt pain. Resident #27 claimed she did not hit her head but complained of left hip pain and left arm pain. Resident #27 was transported to the ER for evaluation . Residents Affected - Some During an interview on 10/24/22 at 2:38 PM, RN J said she had been employed at the facility for 10 months. She said on 10/11/2022 at the time of the incident with Resident #27 she was feeding another resident at the time and a medication aide came in the room and told her that Resident #27 was on the floor. She said when she walked in the room of Resident #27, there was agency CNA I in the room and CNA I said she was transferring Resident #27 and she slid out of the sling. She said Resident #27 was assessed and said her left arm and left hip were hurting and she had sent her out for evaluation at the ER. RN J said CNA I was in the room by herself and that was her first time to work at the facility and she has not been back. RN J said CNA I told them that she had worked at other facilities and was made aware prior to her working on the floor which residents were tube feeders and mechanical lift transfers. She said CNA I said, ok thanks. RN J said the ADON told her to remind CNA I that she needed to have someone with her during transfers with mechanical lift and she reminded CNA I, but she did not ask for help. Resident #27 was sent out to the ER, came back and no fractures were noted. During an interview on 10/24/2022 at 2:46 PM, ADON said the incident with Resident #27 that occurred on 10/11/2022 was with an agency CNA (CNA I). Resident #27 was sent out to the ER because she was complaining of pain. She said staff were in-serviced on mechanical lift usage and she said the agency staff (CNA I) would no longer be able to work at the facility again. She said CNA I was transferring Resident #27 without the assist of 2 people and Resident #27 slid out of the sling to the floor. She said Resident #27 was immediately sent to the ER and all CT scans were negative for fractures. She said she was responsible for ensuring staff were trained on transferring residents using mechanical lifts. During an interview on 10/25/2022 at 9:40 AM, Administrator said agency CNA I transferred Resident #27 in a mechanical lift by herself, and Resident #27 slid out of the lift sling to the floor. She said she interviewed CNA I after the incident and had her write out a statement. She said Resident #27 was immediately assessed by the nurse and was sent out the ER for evaluation. She said CNA I was asked to leave and was on their do not return to work list. She said the CNA's and nurses were in-serviced on safe use of mechanical lifts with 2 person transfers after the incident on 10/11/2022 but was unable to locate the in-service that was conducted. Record review of an Event Report for Resident #27 dated 10/11/2022 by RN J indicated a fall event occurred at the facility on 10/11/2022 at 5:51 PM. Resident #27 was being transferred in a mechanical lift in her room and had a fall. Resident #27 complained of pain in her left hip and left arm. Body observation indicated Resident #27 had limited range of motion on her left side. Resident #27's level of consciousness was alert and she responded to her name, pain, and environment. Record review of a signed statement by CNA I dated 10/11/2022 indicated, Resident #27 slipped out of the Hoyer lift while transferring from bed to wheelchair. This staff asked for assistance from the med aide to go get help. One person transfer with ADL's. I did not ask for assistance with transferring with the Hoyer lift. 676166 Page 2 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a signed statement by ADON dated 10/11/2022 indicated, CNA I from a staffing agency was given report at nurses station of who/which residents needing extensive care, who needed assist with meals, who ate in the dining room, and which of the residents she was assigned to that were Hoyer residents, which also included make her aware to ask for assist with Hoyer transfers, because protocol calls for 2 staff members. RN J was witnessed to all explanations given to CNA I. CNA I failed to ask for assist with transferring Resident #27 with Hoyer, resulting in resident sliding out of the sling. Resident was assessed by RN J with Resident #27 complaining of pain to left hip and left arm. Resident #27 was sent to ER for further evaluation. 2. Record review of a Face Sheet dated 10/25/2022 for Resident #13 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, muscle wasting, and rash. Record Review of a Care Plan dated 8/10/2022 for Resident #13 indicated resident is was highly involved in assisting with ADL needs being primary supervision, set up, cueing to limited assistance of staff. Resident #13 used a wheelchair for primary mobility, does ambulate with a walker when with therapy service. Record review of a Quarterly MDS dated [DATE] indicated Resident #13 had a BIMS score of 5, indicating moderate cognitive impairment. She received set up assist with transfers and propelled self about unit. During an observation on 10/24/2022 at 11:30 a.m. Resident #13's room, a bottle of nail polish remover, approx. 4 oz. was sitting on the bedside table. 3. Record review of a Face Sheet dated 10/25/2022 for Resident #32 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, strain of muscle, cough, and rash. Record Review of a Care Plan dated 10/18/2022 for Resident #32 indicated resident had a debility needing extensive assistance of staff x 2 in transfers to wheelchair and shower chair and going to bed. Resident #32 uses a wheelchair for primary mobility with staff propelled. Resident #32 had potential further decline related to her Alzheimer's Disease. Record review of a Quarterly MDS dated [DATE] indicated Resident #32 had a BIMS score of 15, indicating cognition intact. During an observation on 10/24/2022 at 11:30 am in Residents #32's room revealed a bottle of approx. 8 oz. Alcohol Rub on the bedside table along with a bottle of nail polish remover approx. 4 oz. During an observation and interview on 10/25/22 at 11:51 a.m. with Resident #32 revealed the same bottle of approx. 8 oz. Alcohol Rub on the bedside table along with a bottle of nail polish remover approx. 4 oz., same as observation on 10/24/2022. Resident #32 said she understood why she should not have these at bedside, since there was a resident that walk around the facility and could come into her room. Resident #13 said that it could be a problem if a confused resident drank it. Resident #32 said it was okay with her if the staff removed it due to the rubbing alcohol and nail polish remover being potentially harmful. During an interview with the Activity Director 10/25/22 at 12:10 p.m. the AD said they do have nail 676166 Page 3 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activities that include nail care and painting and the remover should be kept in the activity room locked up. The residents are supervised during use. The AD said the residents should not be allowed to keep polish remover in their rooms due to safety concerns and the potential for a wandering resident to pick it up. During an Interview with the ADON 10/25/22 at 12:15 p.m. she said that the residents cannot have alcohol and polish remover in the rooms, it was a safety hazard. It would be harmful if someone drank it. The ADON said it the Nail polish and alcohol was broought in by fammily and will be removed right away and they do have a resident who wanders in the facility and that could be a problem if she picked it up. During an observation on 10/25/22 at 12:23 p.m. of Resident's#13 and #32's bedside tables, the alcohol and nail polish remover is removed. During an interview on 10/25/22 at 12:26 PM the Administrator said Resident#13 and #32 should not be allowed to keep toxic chemicals at bedside. The polish remover and alcohol will be removed due to potential safety hazards. Record review of a facility policy titled Safety and Supervision of Residents with a revised date of December 2007 indicated, .Our facility strives to make the environment as free from accident hazards as possible. 4. Employees shall be trained and in serviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents . 676166 Page 4 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 26 days (10/5/22 through 10/09/22, 10/12/22 through 10/16/22, 10/19/22 through 10/21/22, and 10/23/22) and designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility. The facility did not provide RN coverage 8 consecutive hours per day, 7 days per week or have a registered nurse employed full time as a DON. This failure could put residents at risk for not receiving care from qualified staff responsible for staff oversight. Findings included: During an interview on 10/25/22 at 11:00 AM, the ADON said that RN coverage had been sporadic since 10/3/22 when the DON left, and the facility still had no full-time DON. Record review of a timecard report dated 06/01/22 to 10/24/2022 for RN J (the only RN employed by the facility) revealed that she only worked on Mondays and Tuesdays with the following hours: 10/3/22 for 12.73 hours 10/4/22 for 11.42 hours 10/10/22 for 11.98 hours 10/11/22 for 12.08 hours 10/17/22 for 12.18 hours 10/18/22 for 12.17 hours 10/24/22 for 12.08 hours During an interview on 10/25/22 at 01:00pm, the Regional Nurse said RN coverage was provided by an agency RN on 10/22/22. Record review of an agency time sheet, dated 06/4/22 through 10/22/22, revealed that there was RN coverage of 13 hours on 10/22/22 by RN K, who was an agency RN. Record review of facility nurse schedule for October 2022 indicated that there was no RN coverage for 10/5/22 through 10/09/22, 10/12/22 through 10/16/22, 10/19/22 through 10/21/22, and 10/23/22. During an interview on 10/26/22 at 9:34 AM, the Administrator said she had 4 DONs recently, but they do not currently have a full time DON. She said that they did have an RN on Monday's and Tuesday's. She said that she could not really think of any risks to the residents by not having an RN in the facility 8 hours per day, as her ADON was wonderful and did a great job with the DON 676166 Page 5 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many responsibilities in the absence of a DON. She said she was aware the facility was required to have a full-time DON and RN coverage in the facility for 8 hours per day, 7 days a week. Record review of a facility policy titled Director of Nursing Services, dated August 2006, stated .The Director is employed full-time (40-hours per week) . also .The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing . Requested policy for RN coverage from Administrator on 10/25/22 at 12:43 pm, none provided prior to exit. 676166 Page 6 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 5 CNAs reviewed for training. (CNAs D, E, F, G, and H). Residents Affected - Some The facility did not complete an annual performance review and provide regular in-service education based on the outcome of these reviews for CNAs D, E, F, G, and H. This failure could place residents at risk of being cared for by staff with inadequate training and skills. Findings Included: Record review of personnel files did not include documentation of any annual performance reviews for: CNA D - hire date of 02/28/2011 CNA E - hire date of 10/30/2012 CNA F - hire date of 05/19/2015 CNA G - hire date of 03/01/2007 CNA H - hire date of 04/02/2018 During an interview on 10/26/22 at 09:34 AM, ADM said that she could not provide any annual competency skills check offs for the CNA's. She said that she had 4 DON's recently and had some paperwork go missing. She said that she was sure that they had been done but was unable to provide proof. She said that ultimately, she was responsible for ensuring that trainings were done, but that the actual training would be done by the DON, or ADON. When asked what risks there could be to residents by being cared for by staff that may not be properly trained, she stated No, I really can't think of any. During an interview with ADON on 10/26/22 at 09:52 AM, she said that she was responsible for ensuring that annual competencies were done on CNA's in the absence of a DON. She said that she was sure that they were done but that they cannot provide any evidence to that fact. She said that there could be a risk to residents if they were cared for by untrained staff, such as infection control risk, and improperly dealing with behaviors with Alzheimer's or dementia residents. Record review of facility policy titled In-Service Requirements, undated, stated .address areas of weakness as determined in nurse aides' performance reviews and facility assessment . 676166 Page 7 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication carts (nurse cart for halls 3 and 4) and 1 of 1 medication rooms reviewed for pharmacy services. The facility failed to dispose of expired medications from the medication storage room. The facility did not dispose of expired medications or date medications when they were opened from the nurse medication cart for halls 3 and 4. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: 1.During an observation in the medication room on 10/24/222 at 3:20 PM with RN J revealed the following: * 2 pack of medicated douches with an expiration date of 6/22. * A bottle of OTC fish oil with an opened date of 12/7/21 and an expiration date of 8/22. * An opened vial of Tuberculin PPD with lot number C5841AB and an expiration date of 6/17/23 had an opened date of 9/21/22. During an interview with RN J on 10/24/2022 at 3:25 PM, RN J said an opened vial of Tuberculin was good for 28 days after opening. She said the medication aides were responsible for stocking the medication room and removing expired medications. She said she only worked at the facility for 2 days a week on Mondays and Tuesdays and tried to remove expired items when she saw them. During an interview on 10/24/2022 at 3:38 PM, ADON said the medication aides were responsible for restocking the medications rooms. She said if Tuberculin was opened it should be used within 30 days. She said the Tuberculin was just out of date by about 3 days. She said she was unaware of the expired medications that were observed in the medication room. She said the pharmacist comes to the facility monthly and was scheduled to come in the next few days and would have let them know if medications were expired or out of date. She said going forward she would be doing more frequent monitoring of the medication room and carts. 2. During an observation of the nurse medication cart for halls 3 and 4 on 10/25/2022 at 9:10 AM with RN J revealed the following: * 1 bottle of glucose tablets (sugar tablets) with an opened date of 5/4/22 and expiration date of 9/22 676166 Page 8 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0761 * 1 bottle of clear lax (liquid laxative) with no open date and expiration date of 6/24 Level of Harm - Minimal harm or potential for actual harm * a bottle of prostat sugar free (supplement for wound healing) with no open date and expiration date of 7/21/23 Residents Affected - Some * 1 box of loperamide 2 mg tablets (diarrhea tablets) no open date and expiration date of 8/23 *tube of Aspercreme (muscle rub) with an open date of 6/24/22 and expiration date of 4/21 During an observation and interview on 10/25/2022 at 11:20 AM, RN J said the facility had been using agency staffing and she had been checking the nurse medication cart on the days she works which was only on Mondays and Tuesdays. She said she did not know the medication cart had expired medications or some of the medications did not have an open date of the OTC's. She said she would dispose of the expired medications, and she dated the bottle of clear lax, prostat sugar free and loperamide 2 mg tablets 10/25/2022 since the medications were not dated. She said OTC medications should be dated the date they are opened. She said if a resident was given medications that were expired, the medications may not provide an effective result. During an interview on 10/25/2022 at 3:30 PM, the ADON said the nurses and medication aides were responsible for ensuring their carts did not have expired medications. She said going forward she would provide more frequent monitoring of the medication carts. She said the facility did not have a DON and she had many things that she was responsible for but would try to do better. Record review of a facility policy titled Storage of Medications with a revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of a facility policy titled Administering Medication with a revised date of December 2012 indicated, .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Record review of the FDA reference 22. [NAME] S, et al. Effect of oxidation on the stability of tuberculin purified protein derivative (PPD) In: International Symposium on Tuberculins and BCG Vaccine. Basel: International Association of Biological Standardization, 1983. Dev Biol Stand 1986; 58:545-552. Accessed at https://www.fda.gov on 10/25/2022 dated 11/9/2020 indicated .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration date . 676166 Page 9 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 1 dietary supervisor (FSS) reviewed for dietary services. The facility did not ensure the Food Service Supervisor (FSS) had the appropriate license, certification, or qualifications. This failure could place the residents who consumed food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: A record review of the FSS personnel file indicates, Employee Salary and /Or Position Change indicated she was hired by facility on 05/19/16, as a cook in the dietary department. She was promoted to FSS on 09/16/21 and given 6 months to complete her certified dietary manager training. During an interview on 10/26/22 at 10:40 a.m., the FSS said she has not had time to step back and do what she needs to do as a FSS. She said she had to work a double today and she worked a double yesterday. She said the reason she had not gotten her Certified Dietary Manager/Certified Food Protection Professional credentialing exam certification is because she had been in a bind working doubles because she's been shorthanded, and things had fell behind. During an interview on 10/26/22 at 10:45 a.m., the FSS said her expectations for the kitchen for her to get her dietary manager certificate as soon as possible During an interview on 10/26/22 10:08 a.m., the Adm said she would have to see what a reasonable time frame is for the FSS to complete her Dietary Manager Certification. She said they had signed her up and paid for an online course titled Nutrition and Foodservice Professional Training, on 01/06/20. The ADM. promoted FSS on 09/15/21 to Food and Nutrition Services Supervisor and she was given 6 months to complete the course. Review of the Dietitian Policy, revised October 2017, indicates If a dietitian is not employed full time (35 or more hours per week) a director of food service management will be designated. This individual will: a. Be a certified dietary manager. b. Be a certified food service manager, or c. Be nationally certified in food service management and safety; or 676166 Page 10 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0801 d. Level of Harm - Minimal harm or potential for actual harm Have an associate's (or higher) degree in food service management or Residents Affected - Few hospitality (must be from an accredited institution and include courses in food service or restaurant management); e. Meet any state requirement for food service or dietary managers; and f. F. receive frequent schedule consultations from a qualified dietitian or qualified nutrition professional. 676166 Page 11 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, Interview and record review the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen. Residents Affected - Some The facility was reusing containers that are labeled by the manufacture and had an expiration date stamped on the container but was not what was inside of the container. There was a container of tomato soup in the refrigerator with a received date of 10/10/22, there was no use by date, or expiration date, on the container. There was a container of ketchup in the refrigerator with a received date of 10/09/22, there were no use by date, or expiration date, on the container. There were chicken tenders in the freezer in a clear plastic bag, there were no date received, no use by date, or expiration date on the bag. These failures could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings Include: . During an observation on 10/24/22 at 11:30 a.m., there were two containers in the refrigerator, one had tomato soup dated 10/10/22 and the other had ketchup dated 10/09/22, containers had dates received on them, but there was no use by dates, or expiration dates on the containers. During an observation on 10/24/22 at 11:36 a.m., there were frozen chicken tenders in a clear bag in the freezer, there was no label on the bag, no date received, no use by date, or expiration date. During an interview on 10/24/22 at 11:38 a.m., with the FSS, she said the staff in the kitchen were supposed to automatically put a sticker on the package when they received it, that includes the date received and use by date. She said it was the responsibility of all staff in the kitchen to check the refrigerator and make sure all foods were labeled and dated with an expiration date. She said it was her responsibility to teach them. During an interview on 10/26/22 at 10:11 a.m., with the ADM., she said her expectations for the kitchen was for all items in the kitchen to be labeled with date received, use by dates, and proper manufactures expiration date. She said not discarding the food on expiration date could cause the residents to get sick. During an interview on 10/26/22 at 10:15 a.m., with the FSS, she said it was her responsibility to make sure her staff in the kitchen, label foods with date received, and use by date. 676166 Page 12 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program that includes reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. Residents Affected - Many The facility failed to provide documentation that demonstrated evidence of their ongoing QAPI program. This failure could place residents at risk for quality deficiencies being unidentified with no appropriate plans or actions to be developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets revealed the following: -Sign in sheet dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. 2021 missing DON signature. No action plans, no interventions or monitoring -Sign in sheets dated March 3/2022, for Third Quarter Data July August Sept. 2021 missing DON signature. No action plans, no interventions, or monitoring. -There is no sign in sheets or meeting minutes for first quarter: Jan, Feb and March 2022. No action plans, no interventions or monitoring -There is no sign in sheet or meeting minutes for second quarter: April, May and June 2022. No action plans, no interventions or monitoring -Sign in sheet dated 09/16/22, for data covered June, July and August 2022. No evidence of review of prior action plans or prior meetings for first and second quarter 2022. During an entrance interview on 10/24/122 at 11:15 a.m., the ADON said the QAA meetings were held quarterly and there had been three different DON hired at the facility in the past year and there was no full time DON on staff or full time RN. During an interview with the Administrator 10/26/22 at 09:40 AM, the administrator said she was responsible for coordination of QAPI, QAPI minutes, and actions plans. The Administrator stated I am looking for the sign in sheets, I can't find them. She said that the QAPI committee had been meeting quarterly, but we are going to start meeting monthly. During an interview on 10/26/22 at 09:45 a.m. the Area Nurse consultant said she was new to this facility since change of ownership in July 2022. The ANC said she was trying to find and organize the QA data for the Administrator. And what was provided was all they could find. During interviews with the Administrator on 10/25/22 at 9:00 a.m. and 4:00 pm. a copy of the Facility QAPI plan, policies were requested and none provided . 676166 Page 13 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0865 Level of Harm - Minimal harm or potential for actual harm Record Review of a generic General Guideline for QAPI Plan provided by the Area Nurse Consultant on 10/26/22 revealed the guideline contains with no date, company name or facility name included and reflected the following: Quality Assurance and Performance Improvement QAPI General Guidelines and documentation Residents Affected - Many Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. Guidelines: The QAPI meeting will be held the second week of month on the same day of the week at the same time. All members must be prepared to discuss the areas of concern in their department, proposed interventions, and progress of the department to improve areas of identified in prior meetings. Each Long-Term facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: * Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements * The following reports should be reviewed prior to the meeting and brought to the QAPI Meeting: 1. Monthly Operation Summary 2. Facility Level Quality Measure Report for the prior 6 months Resident Level Quality Measure Report for the prior 6 months 3. Cumulative skin report 4. Infection Control Tracking and Trending 5. Preventative Health Care Report 6. Incident and accident Tracking and trending report 7. Weight Variance Report for the current month 8. GDR tracking report 9. Quality of care meeting reports 10. Concern/ Grievance reports for the month 11. Pharmacy and dietary consultant reports 676166 Page 14 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0865 12. Admission/ discharge log for the prior month Level of Harm - Minimal harm or potential for actual harm 13. Hospital Representative Visit report 14. Other reports used for PI Residents Affected - Many 676166 Page 15 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the facility's Quality Assessment and Assurance Committee met quarterly, for 1 of 1 facility, reviewed for QAA/QAPI. Residents Affected - Many The facility failed to ensure they provided documentation showing the QAA/QAPI met for the first quarter (January, February, March) and second quarter (April, May, June) during 2022, to address identified issues and that the DON or RN designee attended. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets revealed the following: -Sign in sheet dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. 2021 missing DON signature, no action plans, no interventions or monitoring -Sign in sheets dated March 3/2022, for Third Quarter Data July August Sept. 2021 missing DON signature. no action plans, no interventions, or monitoring. -There is no sign in sheets or meeting minutes for first quarter: Jan, Feb and March 2022. No action plans, no interventions or monitoring -There is no sign in sheet or meeting minutes for second quarter: April, May and June 2022. No action plans, no interventions or monitoring -Sign in sheet dated 09/16/22, for data covered June, July and August 2022. No evidence of review of prior action plans or prior meetings for first and second quarter 2022. During an entrance interview on 10/24/122 at 11:15 a.m., the ADON said the QAA meetings were held quarterly and there had been three different DON hired at the facility in the past year and there was no full time DON on staff or full time RN. During interviews with the Administrator on 10/25/22 at 9:00 a.m. and 4:00 pm. a copy of the Facility QAPI plan, policies were requested, and none provided During an interview with the Administrator 10/26/22 at 09:40 AM, the administrator said she was responsible for coordination of QAPI, QAPI minutes, and actions plans. The Administrator stated, I am looking for the sign in sheets, I can't find them. She said that the QAPI committee had been meeting quarterly, but we are going to start meeting monthly. During an interview on 10/26/22 at 09:45 a.m. the Area Nurse consultant said she was new to this facility since change of ownership in July 2022. The ANC said she was trying to find and organize the QA data for the Administrator. And what was provided was all they could find. 676166 Page 16 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0868 Level of Harm - Minimal harm or potential for actual harm Record Review of a generic General Guideline for QAPI Plan provided by the Area Nurse Consultant on 10/26/22 revealed the guideline contains with no date, company name or facility name included and reflected the following: Quality Assurance and Performance Improvement QAPI General Guidelines and documentation Residents Affected - Many Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. Guidelines: The QAPI meeting will be held the second week of month on the same day of the week at the same time. All members must be prepared to discuss the areas of concern in their department, proposed interventions, and progress of the department to improve areas of identified in prior meetings. Each Long-Term facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: * Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements * The following reports should be reviewed prior to the meeting and brought to the QAPI Meeting: 1. Monthly Operation Summary 2. Facility Level Quality Measure Report for the prior 6 months Resident Level Quality Measure Report for the prior 6 months 3. Cumulative skin report 4. Infection Control Tracking and Trending 5. Preventative Health Care Report 6. Incident and accident Tracking and trending report 7. Weight Variance Report for the current month 8. GDR tracking report 9. Quality of care meeting reports 10. Concern/ Grievance reports for the month 11. Pharmacy and dietary consultant reports 676166 Page 17 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0868 12. Admission/ discharge log for the prior month Level of Harm - Minimal harm or potential for actual harm 13. Hospital Representative Visit report 14. Other reports used for PI Residents Affected - Many 676166 Page 18 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure that the designated individual responsible (Infection Preventionist-ICIP) for the infection control program participated on the quality assessment and assurance committee. The facility did not ensure that the ICIP was a member of the facility's quality assessment and assurance committee and reported to the committee on a regular basis. This failure could affect the facilities ability to appropriately recognize and respond to communicable diseases and infections. Findings included: During an entrance interview and observation on 10/24/22 at 11:15 a.m., the ADON said the QAA meetings were held quarterly. The ADON said that the designated IP worked part-time at the facility as a staff nurse and provided a copy of the IP's certification dated 09/02/20. The ADON said that she was responsible for IC because they had three different RNs in position of DON in the past year and she had taken over the role since 10/03/22 when the DON left. The ADON said she was taking the IP course but had not finished certification for IP. During interviews with the Administrator on 10/25/22 at 9:00 a.m. and 4:00 pm. a copy of the QAPI plan, policies and all sign in sheets since last recertification visit was requested. During an interview with the Administrator 10/26/22 at 09:40 AM, the Administrator said she and the ADON were responsible for coordination of Infection Control activities QAPI, QAPI minutes and actions plans. The Administrator did not have certification for IP. The Administrator said due to overturn in the DON position, a designated IP may not have attended the meetings. Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets provided by the Administrator: Sign in sheets dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. 2021 missing the IPs signature. The only nurse signature was the ADON, ( the ADON had not completed the required IP course for certification) No attached action plans, no interventions or monitoring Sign in sheets dated 03/03/22, for Third Quarter Data July, August, Sept. 2021 missing the IP's signature. The only nurse signature is the ADON, (the ADON had not completed the required IP course for certification) No attached action plans, no interventions or monitoring. There is no sign in sheets or meeting minutes for first quarter: Jan, Feb and March 2022. No action plans, no interventions or monitoring There is no sign in sheet or meeting minutes for second quarter: April, May and June 2022. No action plans, no interventions or monitoring Record Review of a generic General Guideline for QAPI Plan provided on 10/26/22 at 10:16 a.m. by the Area Nurse Consultant, the guideline contains with no date, company name or facility name 676166 Page 19 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0882 Level of Harm - Minimal harm or potential for actual harm included. The undated plan contains no specific plan for the facility. The Example/Generic Plan did not include the requirement for IP to be a member of the facility's quality assessment and assurance committee as required by regulation and report to the committee on the ICIP on a regular basis. The generic plan: Residents Affected - Many Quality Assurance and Performance Improvement QAPI General Guidelines and documentation. Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. Guidelines: The QAPI meeting will be held the second week of month on the same day of the week at the same time. All members must be prepared to discuss the areas of concern in their department, proposed interventions, and progress of the department to improve areas of identified in prior meetings. Each Long-Term facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: * Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. * The following reports should be reviewed prior to the meeting and brought to the QAPI Meeting: 1. Monthly Operation Summary 2. Facility Level Quality Measure Report for the prior 6 months Resident Level Quality Measure Report for the prior 6 months 3. Cumulative skin report 4. Infection Control Tracking and Trending 5. Preventative Health Care Report 6. Incident and accident Tracking and trending report 7. Weight Variance Report for the current month 8. GDR tracking report 9. Quality of care meeting reports 676166 Page 20 of 21 676166 10/26/2022 Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474

F 0882 10. Concern/ Grievance reports for the month Level of Harm - Minimal harm or potential for actual harm 11. Pharmacy and dietary consultant reports 12. Admission/ discharge log for the prior month Residents Affected - Many 13. Hospital Representative Visit report 14. Other reports used for PI 676166 Page 21 of 21