Health inspection·April 9, 2025

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 reviews, the facility failed to 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 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care. Residents Affected - Some The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2. These failures placed residents of the facility at risk of infections from incontinent care. Findings included: Resident #1 Record Review of resident #1's Face Sheet dated 01/10/2025 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), and Lack of coordination. Record review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 06 (severe cognitively impairment). Section H-Bladder and Bowel, resident always incontinent. During an observation on 04/08/2025 at 2:35 PM, CNA-A and CNA-C performed peri-care for Resident #2. CNA-A folded each wipe and reused the folded wipe on the resident. CNA-A also did not pull back and clean the resident's foreskin while performing pericare. During an interview on 04/08/2025 at 2:55 PM, CNA-A stated she had not performed pericare correctly because she folded the wipes and reused. She stated she also had not pulled back the resident foreskin and cleaned it incorrectly. CNA-A stated in not doing so could have caused buildup and lead to an infection. During an interview on 04/08/2025 at 3:00 PM, the DON stated, pericare should have been performed using one wipe, one swipe technique. She stated the wipes were not to be folded. The DON stated pericare should have begun with pulling back the foreskin of the resident and in not doing so, could have resulted with a resident infection. Resident #2 (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 3 Event ID: 455744 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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)