Inspection·January 11, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hours and will provide dates along with the schedules for all the RNs hours on weekends. She stated when they do not have RN coverage, they rely on their LVNs. During an interview on 01/11/2024 at 11:39 a.m., the Administrator stated that the RNs work during the week and every other weekend. She stated it had been a struggle to provide RN coverage. She stated that they have placed hiring ads offering a competitive wage for a RN supervisor but believes that the rural location of the facility was discouraging. During an interview on 01/11/2024 at 12:00 p.m., the VP stated the facility did not have any staffing waivers. During an interview on 01/11/29 24 at 12:25 p.m., the VP stated that the facility does not have any specific staffing policies on RN coverage. She stated that they follow state regulation. She stated they did use two-staffing agencies to assist with staffing coverage. During an interview on 01/24/24 2:29 p.m., the Corporate Nurse stated that the facility utilized a telehealth line for staff to call in for RN advice. She stated that normally, staff call her everyday all day long with concerns and she guides them. She stated corporate considered this facility high risk because it went without a DON and often with no RN coverage. She stated as a result, she monitored the facility's electronic activity board that allows her to view recent orders, progress notes, incidents, and new admissions keeping her aware of the daily needs of residents. She stated that they are actively trying to recruit RNs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 2 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 5 residents (Resident #35) reviewed for medication administration in that: -LVN B failed to administer Resident #35 morning dose of baclofen 10mg by mouth TID. -the facility failed to reorder and administer Resident #35's Vitamin D 50,000-units once a week on Tuesdays per physician order. These failures placed residents at risk for unwanted pain and decrease in quality of life. Findings: Record review of Resident #35's face sheet (no date) revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included the following: cerebral infarction (disrupted blood flow to the brain), vascular dementia (brain damage cause by multiple strokes that cause memory loss) , stiffness of left wrist, muscle wasting and atrophy (decrease in size) pain, low back pain, and vitamin D deficiency. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating that resident cognition was moderately impaired. Record review of Resident #35's Physician Orders revealed an order for Baclofen (used to treat muscle spasticity) 10mg tablet take 1 oral (by mouth) dx low back pain TID at 9:00am, 1:00pm, and 5:00pm order date 08/25/2023. Further review revealed an order dated 08/29/2023 Vitamin D 50,000-unit 1 tablet po once a day on Tuesdays. Record review of Resident #35's Care Plan dated 09/17/2023 and updated on 12/26/2023 revealed that resident was being care planned for pain related to contracture of the left hand and arm from CVA (cerebrovascular accident-stroke). The intervention included administer pain medication as per MD orders. Record review of Resident #35's MAR for the month of January 2024 revealed that resident did not receive the medication Baclofen 10mg TID by mouth at 9:00am on 01/09/2024. Observation on 01/09/2024 at 12:40pm of medication administration by LVN B administering medication Baclofen 10mg 1 tablet by mouth to Resident #35. The LVN did not have the medication Vitamin D 50,000-units available on her medication cart. LVN B went to the medication supply room to see if the facility had the medication Vitamin D 50,000-units in the medication supply room. Further observation was made of the facility not having the medication Vitamin D 50,000-units in the medication supply room. Interview on 01/09/2024 at 12:50PM, LVN B said medication Vit D 50,000-units was ordered to be administered to Resident #35 once a week every Tuesday. LVN B said she missed administering Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 3 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #35's 9:00am dose of Baclofen 10mg po because she had to assist with breakfast in the dining room due to a CNA reporting to work late. LVN B said she would order the medication Vitamin D 50,00-units and the medication should arrive hopefully in the evening on 01/09/2024 when the pharmacy makes a delivery to the facility. LVN B said medications should be ordered a week in advance to ensure the resident (s) received their medications as ordered by the physician. LVN B said the nurse that last administered the medication should have been the one to reorder Resident #35's Vitamin D 50,000-units. Interview 01/09/24 at 12:45PM, the DON said the nursing staff had 1 hour before and 1 hour after to administer medications to the residents. The DON said she was aware that LVN B was assisting in the dining room with breakfast due to a staff member reporting to work late. The DON said the facility census was 43 and therefore, corporate did not allow extra staffing. The DON said she was unsure what the staffing was but believed the facility was staffed with 2 nurses and 3 CNA's. Record review of Resident #35's Progress Notes dated 01/09/2024 by the Regional Nurse revealed the following: .Vitamin D not available MD notified give medication when available to the facility . Interview on 01/09/2024 at 12:38pm, Resident #35 denied that he was in any pain at the present time. Interview on 01/09/24 at 1:20PM, the Regional Nurse said after reviewing Resident #35's medication administration record, she agreed that there were errors in administering the medications baclofen and vitamin D 50, 000-units. The Regional Nurse said the facility was working changing to liberalized medication administration (resident have a decision regarding when to take their medications). The Regional Nurse said the facility would be calling Resident #35's physician regarding the medication discrepancies to see how the physician wanted to proceed. The Regional Nurse said the facility nursing staff consisted of 3 nurses and 3 CNAs with a census of 43 residents therefore it did not require extra staffing. The Regional Nurse said she believed the nursing staff got off schedule when they heard that state was at the facility. Interview on 01/11/24 at 2:15PM, the Regional Nurse said regarding Resident #35's medication Vitamin D 50,000- units by mouth was administered on 01/10/24. The Regional Nurse said the physician was notified on 01/09/24 when the medication was not available at the facility and an order was given to place the medication on hold until the medication arrived at the facility. Further interview with the Regional Nurse said the medication baclofen 10mg by mouth to administer was changed to first dose being administered at 6:30AM instead of 9:00AM. The Regional Nurse said medications should be ordered at least 7 days prior to medication running out. The Regional Nurse said the facility did not have a policy on ordering medications. Record review of the facility policy on Medication Error Reporting and Adverse Drug Reaction Prevention and Detection 09/10 revealed in part: .The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers .Medication error/variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of health care professional, resident, or consumer. Such events may be related to prescribing, order communication, product labeling, packaging, dispensing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 4 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0755 administration, education, monitoring and use . Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy on Medication Administration revised December 2012 revealed in part: .Medication shall be administered in a safe and timely manner, and as prescribed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 5 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are readily accessible for 1 of 8 residents (Resident #1) reviewed for clinical records in that: Residents Affected - Few - Resident # 1 had blood tests that were missing and unavailable for review. This failure could place residents at risk of incomplete records which could impact their treatment and health. Findings include: Record review of Resident #1's face sheet on 1-11-24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cerebral infarction, muscle weakness, dysphagia (oral phase), unspecific lack of coordination, age-related cognitive decline, repeated falls, , type 2 diabetes mellitus with unspecified complications, gout, age-related osteoporosis without current pathological fracture, aphasia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder (single episode, unspecified). Record review of Resident #1's medication orders on 01-11-24 showed she had orders for two antiseizure medications, which were: Depakote (divalproex) tablet, delayed release for 250 mg 3 times a day starting 6/25/22. and Dilantin Extended capsule for 100 mg, 3 tablets at bedtime starting 6/25/22. Record review of the pharmacy review book for Resident #1 on 01-11-24 revealed a Note to Attending Physician/Prescriber from the consultant pharmacist (a pharmacist who reviews residents' medications and makes recommendations such as for adjustments to dosage) dated 2/28/23 which read, The resident is receiving Depakote and Phenytoin without current lab work on the chart. Please consider ordering Depakote and Phenytoin levels on the next lab day and repeat every 6 months to monitor therapy. Thank you. Underneath the Physician responded in agreement and ordered labs for Phenytoin and Depakote levels on 5/9/23. Record review of Resident # 1's clinical records revealed a physician's progress note dated 5/9/2023 which read, NP in to see resident today and noted per pharmacy recommendation to obtain Depakote and Phenytoin level on next lab draw. Further review revealed no record of the lab results. Record review of pharmacy review book revealed that the pharmacist consultant (PC) had written the same note for Resident #1 on 10/31/23 and 11/30/23, writing, Please investigate as the following lab results could not be located in this resident's chart: Depakote and Dilantin levels. Dilantin is the brand name for Phenytoin. Interview with the ADON on 1/11/24 at 12:44pm, the ADON said that she found one lab for Resident #1 dated 12/20/23. She did not see any other labs. She was unable to confirm other labs for resident were done, as she said the old laboratory company terminated the facility's online access to resident lab results. When asked what the purpose of lab monitoring was, she said it was to control levels and medications, to increase or decrease dosage when needed. Interview with the DON on 1/11/24 at 12:50pm, the DON said that she could not locate the labs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 6 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0770 Level of Harm - Minimal harm or potential for actual harm because the facility switched lab company at the end of October 2023, and they did not have a paper copy of Resident #1's Depakote/Dilantin labs besides the one performed on 12/20/23. She said it was hard to access the lab results with the old company and she would have to call them and request it. She could not locate the lab results in the resident's paper chart. She could not specify how long it would take to receive the labs results. Residents Affected - Few Interview with the RN on 1/11/24 at 1:03pm, the RN stated that physicians and surveyors should have access normally when needed, and that this was not the norm. The RN, LVN A and the ADON were working together and attempting to log into the laboratory website using the facility's login information and could not locate the lab results through the old portal. When asked what the purpose of monitoring labs were, she said that it was to not miss diagnoses and to know how to adjust dosage when needed. Interview with the PC on 1/11/24 at 3:07pm, the pharmacist had requested labs for Resident #1 for May, October, and November of 2023 but to his knowledge have not seen lab results since June. When asked where they would be located, he said in resident's chart. When asked what his procedure is if he doesn't receive the requested test results, he said it was to keep requesting them. Interview with Resident #1's physician on 1/11/24 at 4:35pm, he said the resident has not had seizures. He said he has Resident #1's Depakote/Dilantin test results for 12/20/23. He does not recall seeing Resident #1's labs for the previous months. Review of the facility's policy Medication Regimen Review and Reporting dated November 2017 reviewed on 01-11-24 stated that, The nursing care center assures that the consultant pharmacist has access to residents and the residents' medical records . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 7 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 01-09-24 at 8:29 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-size dumpster 1/3 full of garbage. The left top lid was dented and located inside the dumpster, and the right lid was open. Interview on 11-09-24 at 9:37am, with the DM, she stated that the dumpster lids always must be closed to keep animals, rain, and debris out of the dumpster. She said she goes out there in the evening to monitor the dumpster. Interview on 11-10-23 at 1:36pm with the Maintenance Director, he stated that he is the one responsible for everything outside the building, including overseeing the dumpster. He said that kitchen staff and housekeeping have access to the dumpster. His responsibility is going out there every morning during his shift to check on the dumpster. He believed either a staff member did not close it at night or someone from the community might have come to dump things in, stuff that doesn't belong. It was important for properly closed lids so that the elements like rain doesn't fill up the dumpster. Record review of facility's policy and procedure, revised December 2008, titled Food-Related Garbage and Rubbish Disposal, reflected, garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin and outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 8 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 12 residents (Resident #30) reviewed for infection control. Residents Affected - Few -The facility failed to change Resident #30's oxygen nasal cannula tubing and humidifier bottle. This failure placed residents at risk for unwanted infection and hospitalization. Findings: Record review of Resident #30's face sheet(not dated) revealed a 71year old male admitted to the facility on [DATE] with diagnoses that included the following: malignant (cancerous) neoplasm (abnormal growth of tissue) of pancreatic duct (drains fluid into the small intestine), malaise (feeling of discomfort that consist of pain and fatigue), iron deficiency anemia (low red blood cell count), and chronic obstructive pulmonary disease (lung disease restricting air flow making it difficult to breathe). Record review of Resident #30's admission MDS dated [DATE] revealed that resident BIMS score was 15 indicating resident cognition was intact. Record review of Resident #30's Physician orders revealed the following order dated 10/27/2023 O2 at 2 liters per minute to keep O2 sats above 92% every shift. Further review did not reveal orders to change resident oxygen equipment. Record review of Resident #30's Care Plan dated 11/19/2023 and updated on 01/10/2024 revealed that resident was being care planned for COPD with an intervention that included the following: administer oxygen PRN or as ordered. Record review of Resident #30's General Administration History/TAR for the month of January 2024 revealed that the facility was administering oxygen to resident at 2 liters to keep O2 sat above 92%. Further review did not reveal any documentation of Resident #30's oxygen equipment being changed. Observation on 01/09/24 at 9:28AM revealed Resident #30 awake in bed wearing oxygen via nasal cannula at 2 liters. Further observation was made of resident's oxygen tubing and humidifier bottle was not dated. Resident had small amount of clear fluids inside of the oxygen tubing. Resident removed the tubing from his nose. Further observation was made of resident not in any respiratory distress. Resident used his call light to call for the nurse. Interview on 01/09/2024 at 9:30AM, Resident #30 said his oxygen cannula tubing had not been changed in about 2-3 and weeks and noticed a little water in the tubing. Resident said he was going to take off tubing for now until his oxygen tubing was changed. Resident said he could breathe without difficulty. Observation on 01/09/2024 at 12:50PM revealed Resident #30 wearing oxygen nasal cannula at 2 liters. The oxygen equipment (oxygen tubing and humidifier bottle) was not labeled. Further observation was made of an oxygen humidifier bottle along with oxygen tubing inside of resident trash can at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 9 of 10 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 676166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Sealy 1401 Eagle Lake Road Sealy, TX 77474 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 0880 bedside. Level of Harm - Minimal harm or potential for actual harm Interview on 01/09/2024 at 12:55PM Resident #30 said LVN A had come to his room and changed his oxygen tubing as well as the humidifier bottle. Residents Affected - Few Interview on 01/10/2024 at 11:08AM, LVN A said she was told by another nurse who name she did not want to share said not to date oxygen equipment. LVN A said she did not know why the nurse told her this but think it had something to do with when the last time the state was at the facility. LVNA A said the oxygen tubing was supposed to be changed every week on a Sunday. LVN A said this was done for infection control purposes. LVN A said she would think the oxygen tubing needed to be labeled so the nurse could see when the last time the equipment had been changed. Interview on 01/10/24 at 11:15AM, the Regional Nurse said the facility stopped dating oxygen equipment about 2 years ago and documenting in the resident records when oxygen equipment was last changed. The Regional Nurse was unable to provide documentation of Resident #30's oxygen equipment was being changed. The Regional Nurse said after reviewing resident records including Physician orders, she could not find an order for changing resident oxygen equipment. The Regional Nurse said she would have to get an order to change the oxygen equipment and that Resident #30 should have had an order to change oxygen equipment. The Regional Nurse said the nurses should be documenting in the TAR when resident oxygen equipment was being changed. The Regional Nurse said the facility did not have a policy on maintaining oxygen equipment. Further interview with the Regional Nurse said the nurses were supposed to be changing oxygen equipment weekly on Sunday. The Regional Nurse said this was done for infection control and to prevent any respiratory infections. Record review of the facility policy on Infection Control revised August 2012 revealed in part: .Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676166 If continuation sheet Page 10 of 10