Inspection·April 5, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 reviews the facility failed to ensure a resident that was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 4 (Resident #1) reviewed for Activities of Daily Living. Residents Affected - Few The facility failed to ensure Resident #1's adult brief was checked and changed when needed. This failure could affect all residents that required staff assistance with activities of daily living and could result in poor hygiene and skin breakdown. Findings Included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessel supply), atrial fibrillation(an irregular, often rapid heartbeat commonly caused by poor blood flow), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), vascular dementia (brain damaged from multiple strokes), unsteadiness on feet (when gait and balance issues makes it difficult to stand and walk). Record review of Resident #1's annual MDS dated [DATE] revealed Section C0500- Brief interview of mental status as coded as 05 (severe cognitive impairment). Section GG 0130- Functional Abilities and goals revealed C. Toileting hygiene- The ability to maintain perineal hygiene was coded as 3, which represented Partial/moderate assistance in which the helper does half of the effort. Section GG0170revealed F. Toilet transfer was coded as 3, which represented partial/moderate assistance in which helper does half the effort. Section H0300- Urinary Continence was coded as 2 for frequently incontinent. H0400. Bowel incontinent was coded as 2 for frequently incontinent. Record review of Resident #1's care plan dated 10/05/2022 and revised on 10/18/2023 revealed Resident #2 had an ADL self-care performance deficit r/t dementia, impaired balance and late effects of CVA. Interventions: Bed mobility: Limited assist X1 staff. Toileting: Extensive assist X 1-2 staff and Transfer: Limited X2 staff. Resident has bladder/bowel incontinence r/t dementia and requires assistance with toileting hygiene. Interventions: Check [NAME] as indicated and as required for incontinence. Wash, rinse and dry perineum. Observations of Resident #1 revealed: 3/28/2024 at 3:07pm- Strong urine odor in Resident #1's bedroom. He was asleep. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676314 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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)