Health inspection·October 1, 2024

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 review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 92 days reviewed. (April 2024, May 2024, and June 2024). The facility did not have RN coverage for 4 days in June 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings: Record review of the Center for Medicare and Medicaid Services PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1 through June 31, 2024) indicated there were no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU). Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30. During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said the corporate travel nurses were not available at that time. He said that they were utilizing agency registered nursing staff to provide the required 8 hours daily coverage but on those occasions the nurse had called in prior to the shift. He said that the staffing agency did not try to find replacements for the dates that the nurses called in. He stated the DON was the only RN on staff at that time and she had left. The Administrator said that he has hired a weekend RN since then. He said that he expected a licensed registered nurse to be on the schedule for 8 hours a day. He said that the DON was to provide RN coverage if there was not an RN on the schedule . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition. During an interview with the corporate compliance officer on 10/1/2024 at 2:15 PM, she said that on Page 1 of 12 455565 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage . Record review of a facility policy titled Staffing dated 9/28/23 indicated .The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 455565 Page 2 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 9 residents (Resident #31) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception). The facility failed to obtain a signed consent for psychotropic medications for Resident #31 that included: mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa that were administered to her. The failure could affect residents who received psychoactive medications without informed consents and place residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of a face sheet for Resident #31 dated 10/1/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of manic episodes (racing thoughts, pressure speech, increased risk-taking and a decreased need for sleep), senile degeneration of brain (progressive loss of brain tissue and function), alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia. Record review of a Sig Change MDS dated [DATE] for Resident #31 indicated she was rarely/never understood. During the 7 day look back period she took antipsychotic, antianxiety and antidepressant medications. She received antipsychotic medications since admission. Record review of active physician orders dated 10/1/2024 for Resident #31 indicated orders for: o Mirtazapine (an antidepressant used to treat major depressive disorder) 15 mg at bedtime started on 6/11/2024. o Risperdal (risperidone-an antipsychotic that works by changing the effects of chemicals in the brain) 1 mg at bedtime started on 6/11/2024. o trazodone (an antidepressant used to treat major depressive disorder) 150 mg at bedtime started on 6/29/2024. o Depakote (used to treat seizure disorders, certain psychiatric conditions and to prevent migraine headaches) 125 mg twice a day started on 7/1/2024. 455565 Page 3 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0758 o Level of Harm - Minimal harm or potential for actual harm clonazepam (used to prevent and control seizures) 0.5 mg three times a day started on 7/9/2024. o Residents Affected - Few Zyprexa (used to treat severe agitation associated with certain mental/mood conditions) 5 mg daily started on 7/9/2024. Record review of the pharmacist's medication regimen review dated 6/1/2024 and 6/24/2024 indicated Resident #31 was reviewed and did not require any recommendations. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antipsychotic medication Risperdal and Zyprexa with diagnosis of alcohol abuse with alcohol-induced psychotic disorder. Interventions included to assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antidepressant medication Mirtazapine. New order for trazodone on 6/17/2024 for diagnosis of insomnia. Interventions included to administer medications as ordered and assess/record effectiveness of drug treatment. Record review of a care plan for Resident #31 dated 6/17/2024 indicated she was at risk for adverse consequences related to receiving antianxiety medication for treatment of anxiety, new order for clonazepam. Interventions included to assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others. Monitor for drug use effectiveness and adverse consequences. Record review of the Resident #31's medical record indicated there were not any consents for the psychotropic medications that were ordered. During a joint interview on 10/1/2024 at 2:07 PM, the Travel DON and the ADON both said that a previous Travel DON who was no longer employed at the facility was responsible for ensuring residents on antipsychotics had consents and appropriate documentation. The ADON said she was hired at the facility on July 23, 2024, and was responsible for antipsychotics as of last week. Both said they started an audit of the facility last week for residents on psychotropics medications and found that residents consents were scanned in different places but Resident #31 did not have any record of consents in her electronic health record. Both said on 9/26/2024 they spoke to Resident #31's RP and received verbal consent at that time and have since gotten signed consents for her medications as of 9/26/2024. Both said consents should be signed before medications were administered, complete an AIMS assessment, have target behaviors in an order along with behavior monitoring, side effects, and care planned for the medications. Both said there was a risk for adverse side effects and family not being aware if consents were not obtained before the medication was administered. Both said going forward they would monitor daily to make sure the consents were signed before psychotropic medications were given. Both said a PIP was put in place and started last week for psychotropic medications. During an interview on 10/1/2024 at 2:19 PM, the Administrator said the DON would be responsible for ensuring residents had consents for psychotropic medications. He said he was aware of Resident #31 not having signed consents as the facility conducted an audit about a week or so ago and found some 455565 Page 4 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few issues. He said the facility put a PIP in place at that time. He said consents for psychotropic medications should be done before the medications were given to the residents. He said there was a risk for getting something the resident or POA did not want them to have. Record review of a Performance Improvement Plan: dated 9/23/2024 indicated they had identified concerns related to antipsychotic medications and making sure consents were obtained. Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for mirtazapine by the RP for the use of the prescribed medication. Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for Depakote by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication for Resident #31 dated 9/26/2024 indicated a consent for clonazepam by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication for Resident #31 dated 10/1/2024 indicated a consent for trazodone by the RP for the use of prescribed medications. Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Risperdal by the RP for the use of the prescribed medications. Record review of a consent for use of psychotropic medication form 3713 for Resident #31 dated 9/25/2024 indicated a consent for Zyprexa by the RP for the use of the prescribed medications. Record review of a facility policy titled Psychoactive Medication dated July 2024 indicated, .Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the residents, as demonstrated by monitoring and documentation of the residents' response to the medication. 9. Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency). a. A consent form for antipsychotic/neuroleptic medication utilizing Texas form 3713 must be completed and signed by the residents or resident representative. Consent must be obtained in writing. b. A consent form for other psychotropic medications must be completed and signed by the resident or resident representative using the psychoactive consent form in Matrix . 455565 Page 5 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

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 observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. Residents Affected - Many The facility did not ensure baking sheets did not have brown and/or black baked on build up on 9/30/2024. The facility did not ensure the chemical sanitizer for the dish machine was at the appropriate sanitization according to the manufacturer's guidelines for the machine from 9/1/2024-9/30/2024. The facility did not ensure scoops were not left in a bin that contained flour on 9/30/2024. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During an observation and interview on 9/30/2024 during the initial tour of the kitchen at 9:05 AM indicated the dish machine was ran by the DM and after the final rinse she checked the chemical sanitizer with a test strip. She said it was 200 ppm. The State Surveyor questioned her if that was accurate, and she took the color code indicator strip out of the tube and looked at the test strip, and said it was 100 ppm. She said the dish machine had been between 100-200 ppm for the past couple of weeks. A manufacturer's label on the machine indicated the operating requirements indicated: 2. Chlorine residual 50 ppm minimum. Record review of the kitchen sanitation test log was reviewed and for the entire month of September 2024 in the AM, Noon, and PM shifts. Sanitation was recorded at 100-200 ppm. During an observation on 9/30/2024 at 9:13 AM, in the dry storage area a container of a white, powdery substance had a scoop inside of the bin lying on top of the powdery substance. During an observation and interview on 9/30/2024 at 9:14 AM, there were 6 large baking sheets with brown and/or black baked on build up that were stacked on top of each other. The DM said they had ordered more baking sheets and cleaned them the best that they could. During an interview on 9/30/2024 at 9:15 AM, the DM said the white, powder substance was flour, and it should not have a scoop inside of the container and said it should be stored in a plastic bag. She said everyone who worked in the kitchen was responsible for ensuring the scoop was not inside the container. She said she would contact someone about the dish machine. She said they had been running it at 200 ppm. During a follow-up observation and interview on 9/30/2024 at 2:30 PM of the kitchen, the DM was present and said a technician came out that morning 9/30/2024 and serviced the dish machine and told her that the sanitization should be between 50-70 ppm, not 100 ppm. She said she told him it had been running high at 200 ppm and he told her it was too high. She said she did not know of anything that could happen to the residents if the sanitization was too high. She ran the dish machine and tested the sanitization, and it was reading at 50 ppm. 455565 Page 6 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a phone interview on 9/30/2024 at 2:55 PM, the Auto Chlor technician said the dish machine had a box timer that indicated when sanitization chemical needed to be added and it was adjusted so the correct amount would be included in the wash cycle. He said they usually liked to keep the sanitization at about 75 ppm. He said if the sanitization was reading 200 ppm, he did not think it would affect anything. He said sometimes the machines would read high if the cam broke, but it should be at a minimum of 50 ppm and not over 100 ppm with the water temp of 120 degrees. During an interview on 10/1/2024 at 8:11 AM, the DM said they noticed about 2 weeks ago that the dish machine's sanitization was in the range of 100 ppm-200 ppm. She said she contacted Auto Chlor and talked to someone who told her that someone would be out for service. She said she was not sure if someone had been out to the facility or not after she called for service as she could have been off work. During an interview on 10/1/2024 at 2:25 PM, the Administrator said the DM was responsible for oversight in the kitchen and he always thought the dish machine sanitization had to be a minimum 50 ppm and could not be more than 100 ppm with 200 ppm being the cut off. He said he thought the sanitization was fine with the dish machine. He said he planned to do an in-service training with the kitchen staff so they would follow the recommendations that the vendor had requested. He said scoops should not be left in the bins of dry goods as the kitchen had drawers for clean utensil storage. He said there was minimal risk to the residents if the sanitization chemical was high as the dishes were ran through the machine, allowed to air dry, and not served directly after being washed. He said he ordered new baking sheets for the kitchen as of 9/30/2024. Record review of a purchase order dated 9/30/2024 for the kitchen indicated the Administrator had ordered 8 aluminum sheet pans. Record review of a facility policy titled Food Storage undated indicated, .To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry Storage Rooms e. Provide scoops for items stored in bins, such as sugar, flour, rice, and other items. Store scoops covered in a protected area near the food containers . Record review of a facility policy dated 2018 indicated, .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120 degrees. c. Chemicals added for sanitization purposes must be automatically dispensed. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used . Record review of the Food and Drug Code dated 2022 indicated, .4-302.14 Sanitizing Solutions, Testing Devices. Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic . 455565 Page 7 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interviews and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the third quarter April 1, 2024 to June 31, 2024) The facility failed to submit accurate RN hours for: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU) These failures could place residents at risk for personal needs not being identified and met. The findings included: Record review of the CMS PBJ (Payroll Based Journal) report for the third quarter of 2024 (April 1, 2024 through June 31, 2024) indicated there was no RN hours for the following dates: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU). Record review of the monthly staffing schedules for April 2024, May 2024, and June 2024 revealed that there was a RN scheduled for most of the days in the report. Time sheets provided for proof of RN coverage on all dates except for 06/15, 06/16, 06/29, and 06/30. During an interview on 10/01/2024 at 2:09 p.m., the Administrator said that he had been employed here since August of 2023. The Administrator stated that during the time of reporting staffing, there was not RN coverage on 6/15/24, 6/16/24, 6/29/24, and 6/30/24. He stated during that time period, the Director of Nurses at that time left the position and he did not have any other RN's on staff. The Administrator said that during that reporting period, corporate was responsible for reporting the hours. He said that hours were assessed through the payroll system and that any registered nurse hours provided by the DON, traveling corporate nurses, and agency nurses would not be reflected in the payroll system. He stated that at that time the Administrators did not review the hours being reported to ensure that all hours were captured. The Administrator stated that since that time, the company has changed the process and that he reviews the hours prior to reporting so that the report can be accurate prior to the hours being submitted to CMS (Center for Medicare and Medicaid Services) . He stated that failure to have an RN in the building could result in not having staff available to assess and recognize changes in resident condition. In an interview with the corporate compliance officer on 10/01/2024 at 2:15 PM, she stated that on the dates that there was not an RN in the building, there was not an RN employed by the facility, and the corporate RN's were not available. She said that with the onboarding of a new DON and hiring of a weekend RN has resolved the issue of no RN coverage. The corporate compliance officer said that the tracking of RN hours has changed and that a new process has been put into place so that the facilities can make sure that information being reported is accurate. She said that the administrators 455565 Page 8 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0851 were able to review hours so that any traveling nurses or corporate nurse hours are captured . Level of Harm - Minimal harm or potential for actual harm During an interview with the corporate director of data analysis on 10/02/2024 at 10:45 AM she stated that she has been with the company for 9 months. She said that she was responsible for submitting the facilities hours to the PBJ system. She stated that during the reporting period in question she obtained the hours for reporting through the company payroll system. She said that any hours that were related to the DON, traveling nurses, or agency would not be available in the payroll system. She stated that she missed the hours for the registered nurses that were in the category of the DON, travel nurses, and agency during that reporting period. She stated that it was an oversite. The director stated that a new system was now in place, that the hours that were not in the payroll system flow through a different system and the hours were captured accurately now. She said that the administrators at each facility were also reviewing the hours prior to being reported to make sure that all hours were reported accurately. Residents Affected - Many Record review of the Facility Assessment Tool dated 6/26/24 with a QAPI (Quality Assurance and Performance Improvement) committee review date of 8/19/24 indicated their plan for staff indicated one RN or LPN each 12-hour shift and a DON RN full-time Days. Record review of a facility policy titled Staffing dated 9/28/23 read .Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. 455565 Page 9 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

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 observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #14 and #25) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA B properly performed hand hygiene during incontinent care to Resident #14 on 9/30/2024. The facility failed to ensure LVN A properly cleaned reusable equipment when providing care to Resident #25 on 9/30/24. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of a facility face sheet dated 10/01/2024 indicated Resident # 14 was a [AGE] year-old male and admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side (unable to move is non-dominate side following a stroke). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #14 had a BIMS score of 09 indicating moderately impaired cognition and was incontinent of bladder and bowel. Record review of a comprehensive care plan dated 8/17/24 indicated Resident #14 was incontinent of bowel and bladder and provide incontinent care as needed. During an observation on 9/30/24 at 2:45 pm Resident #14 was provided incontinent by CNA B and CNA C. Both CNA's washed their hands and applied gloves. Resident #14 was rolled from side to side to remove the lift sling and clothes. Both CNA's removed their gloves, sanitized hands, and applied clean gloves. CNA B opened Resident #14's soiled brief and used wipes to clean the front perineal area of Resident #14. CNA C rolled Resident #14 to right side and CNA B cleaned Resident #14's back peri area. Without changing gloves or performing hand hygiene, CNA B placed a new brief under Resident #14 and applied barrier cream to his buttocks. CNA C assisted Resident #14 to his back and CNA B applied barrier cream to his front peri area and pulled the clean brief into place. CNA B removed her soiled gloves and applied clean gloves without hand hygiene. CNA B then repositioned Resident #14 in the bed and adjusted his bed and call light. Afterwards, both CNA's removed their gloves and washed their hands before leaving the room. During an interview on 9/30/24 at 3:07 pm CNA B said she had been a CNA since 1993 and employed at the facility for 3 months. She said she had been trained on incontinent care and hand hygiene and she should have changed her gloves and performed hand hygiene before applying Resident #14's clean brief and performed hand hygiene between glove changes. She said by not doing so could cause infections. 2. Record review of a facility face sheet dated 10/01/2024 indicated Resident # 25 was a [AGE] year-old male and admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral 455565 Page 10 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0880 infarction affecting right dominant side (unable to move is dominate side following a stroke). Level of Harm - Minimal harm or potential for actual harm Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 08 indicating moderately impaired cognition and was incontinent of bladder and bowel. Residents Affected - Few Record review of a comprehensive care plan dated 9/04/24 indicated Resident #25 had an ostomy and was provided ostomy care every shift. During an observation on 09/30/24 at 10:30 AM Resident #25 received ostomy care from LVN A. LVN A washed her hands and applied gloves. Supplies were set up on clean working area. LVN A dropped her scissors on the floor, picked them up, washed the scissors under cold water for 3 seconds and placed her scissors on the clean work area. LVN A removed her gloves, hands washed, and new gloves applied. LVN A removed soiled ostomy bag (bag outside the body that collects stool), removed gloves, sanitized her hands, and applied new gloves. LVN A used the soiled scissors to cut the opening in the ostomy wafer. LVN A then cleaned around the stoma and using wipes. LVN A then removed her gloves, sanitized her hands, and applied new gloves. LVN A then applied skin prep around the stoma site and applied paste to the ostomy wafer. LVN A applied new ostomy wafer and bag to Resident #25's skin and sealed. LVN A removed gloves and washed her hands. During an interview on 09/30/24 at 10:38 AM LVN A said she had worked at the facility since January 2024 and had been trained on infection control. She said when the scissors dropped on the floor, she should have cleaned them with an appropriate cleaner. LVN A said by not cleaning them appropriately it could cause infections. During an interview on 10/01/24 at 2:20 PM the ADON said she had worked at the facility since July 2024 and was the infection preventionist. She said she and the DON were responsible for the training of all staff on infection control measures. She said CNA B and LVN A had been trained on infection control and retrained on 9/30/2024. She said there had been lots of turn over with management nursing staff and she and the current DON were working on retraining all staff in all areas of care. She said that by not properly cleaning multi-use equipment and performing hand hygiene correctly it could lead to the spread of infections. During an interview on 10/01/24 at 2:25 pm the travel DON said she had worked at the facility for 3 weeks and she and the ADON have been working on retraining all staff on infection control as well as other areas. She said prior to her coming to the facility she was unsure on the training process, but she was working with management to put in place a new training program and would monitor weekly to ensure the program was working. She said if staff were not properly cleaning multi-use equipment and performing proper hand hygiene during incontinent care it could cause the spread of infections. She said she expected the staff to follow infection control measures. During an interview on 10/01/24 at 2:48 pm the Administrator said he had been at the facility 14 months and the DON and the ADON were responsible for the infection control program. He said infection control training was completed on hire and annually. He said there had been turnover of management and was in the process of getting all staff retrained. He said the risk of not following infection control measures were it could spread infections. He said he expected all staff were following policy and procedures for infection control measures. Record review of training report dated 01/13/2024 indicated LVN A had been trained on infection control. 455565 Page 11 of 12 455565 10/01/2024 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0880 Record review of training report dated 7/23/2024 indicated CNA B had been trained on infection control. Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Handwashing/Hand Hygiene dated 1/20/2023 indicated, .this facility considers hand hygiene the primary means to prevent the spread of infections. 5. Hand hygiene must be performed prior to donning and after doffing gloves . Residents Affected - Few Record review of a facility policy titled Perineal Care dated 1/20/23 indicated, .Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene . Record review of a facility policy titled Cleaning and Disinfecting Non-Critical Resident Care items dated April 2020 indicated, .reusable items are cleaned and disinfected or sterilized . 455565 Page 12 of 12