Health inspection·July 1, 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 observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Residents (Resident #1) reviewed for infection control and transmission-based precautions policies and practices. Residents Affected - Few 1. CNA A failed to don the appropriate PPE before she entered Resident #1's room. This failure could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: Record review of Resident #1's face sheet, dated 07/01/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: chronic obstructive pulmonary disease, unspecified (progressive lung disease that makes it hard to breath), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy, with other diabetic arthropathy disease or disorder of joints), and hypertensive heart disease without heart failure (caused by long term high blood pressure but without the hearts inability to pump blood effectively). Record review of Resident #1's admission Minimum Data Set assessment, dated 06/16/25, revealed Resident #1 had a BIMS score of 15, which indicated she was cognitively intact. Record review of Resident #1's care plan, with an initiation date of 01/31/25, revealed Resident #1 had a focus of, [Resident #1] has a diagnosis of COVID 19 . with an initiation date of 06/17/25 and an intervention of Implement isolation precautions ordered/necessary. with an initiation date of 06/17/25. Record review of Resident #1's physician's orders, reviewed from 06/12/25 to 07/01/25 did not reveal any order related to isolation precautions. Record review of Resident #1's nursing note, dated 06/17/25 at 2:18AM by LVN B, stated Resident is COVID positive. Droplet precautions are in place for resident. Record review of Resident #1's nursing note, dated 06/25/25 at 11:50 PM by LVN B, stated Resident is on isolation due to being COVID (+) day 9/10. Page 1 of 3 455923 455923 07/01/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident #1's signage posted on the outside of her door on 06/25/25 at 11:04 AM revealed the resident was on contact, droplet and airborne precautions. Observation on 06/25/25 at 11:04 AM revealed prior to entering Resident #1's room, who was COVID positive and on contact, droplet and airborne precautions, CNA A donned gloves, gown and an N95 (respirator) over her surgical mask which was already in use. CNA A did not don any eye protection or face shield prior to entering Resident #1's room. CNA A was in Resident #1's room for approximately 10 minutes until 11:14 AM when she exited the room with her N95 mask worn over her surgical mask. During an interview with CNA A on 06/25/25 at 11:15 AM, she stated Resident #1 was COVID positive, and on droplet and airborne precautions. CNA A stated when entering Resident #1's room, or residents who were on the same precautions, staff should be using face masks, gowns, and gloves, and stated currently they were wearing regular (surgical) face masks in the building and used N95's over the surgical masks when entering rooms with residents on precautions and then would remove the N95 after exiting the room and kept the surgical masks on. CNA A stated when entering Resident #1's room she wore her N95 over her surgical mask and stated she had worn her PPE correctly. CNA A stated she was trained over these procedures by RN C a couple of weeks prior and she was told to use the N95 and had not been told to put the N95 over the surgical mask but had seen others doing it so she did is as well. CNA A stated no one told her anything about her use of an N95 over a surgical mask and stated no one ever said not to use the surgical mask underneath. CNA A stated based off the droplet precautions and the training from RN C she had to make sure her eyes, mouth, and nose were fully covered, and she they were all covered except for her eyes. CNA A stated she wore her N95 over her surgical mask because that's what she had seen before and for double precautions. CNA A stated she could not comment how her N95 should have been worn because they had not told her anything. CNA A stated it was important to wear her N95 and all PPE appropriately to protect both the resident, and herself from any bacteria. CNA A was unable to comment on the facility policy in regard to PPE use and stated to the best of her knowledge she did follow the facility policy. CNA A stated not wearing an N95's and PPE appropriate could negatively impact the residents because both the resident and herself could get sick. During a follow up interview via telephone on 07/01/25 at 2:43 PM, CNA A stated she was not wearing a face shield or eye protection when she entered Residents #1's room on 06/25/25. CNA A stated she should have been wearing eye protection but did not see any face shields. CNA A stated they had sufficient N95 masks but did not know if they had sufficient eye protection or face shields for use. During an interview with RN C on 07/01/25 at 3:31 PM, she stated she was the infection preventionist. RN C stated on 06/25/25, Resident #1 was COVID positive and was on contact, airborne and droplet precautions. RN C stated when working with COVID residents' staff should use gowns, gloves, face shields or goggles and an N95 mask. RN C stated staff which included CNA C were trained over those procedures monthly by her and RN D. RN C stated an N95 mask should be used as the primary mask and should be put on first. RN C stated placing a surgical mask underneath an N95 would break the seal and the N95 was used to create a seal. RN C did not have an answer for why CNA A wore her surgical mask under her N95. RN C stated CNA A should have worn eye protection when entering Resident #1's room and did not have an answer as to why she did not. RN C stated isolation carts were stocked with both goggles and face shields. RN C stated they had sufficient N95's for staff and sufficient face shields and eye protection for staff to use. RN C stated it was important to wear N95's and PPE appropriately to protect yourself and other people who they took care of. RN C stated they did not want to spread germs around from people who were COVID positive and stated wearing PPE appropriately stopped the spread of the virus. RN C stated the facility policy stated when anybody was on contact, droplet or 455923 Page 2 of 3 455923 07/01/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0880 Level of Harm - Minimal harm or potential for actual harm airborne precautions, they educated the use of PPE was important and PPE and the use of appropriate PPE was a priority when someone had the flu, a cold or anything contagious. RN C stated CNA A did not follow the facility policy and CNA A did use an N95, but did not use a face shield. RN C stated not appropriately wearing N95's or PPE could negatively impact residents because it could spread COVID and other contagious viruses. Residents Affected - Few During an interview with the DON on 07/01/25 at 4:00 PM, she stated on 06/25/25 Resident #1 was COVID positive and was on contact and airborne precautions. The DON stated when working with COVID residents' staff should use gowns, gloves, face shields and an N95 mask. The DON stated staff which included CNA A were trained over those procedures frequently by RN D. The DON stated CNA A did not wear her N95 correctly when she wore a surgical mask under it, when entering Resident #1's room on 06/25/25 and that was not how it should have been worn and the N95 should go first. The DON stated CNA A told her she previously had COVID and still had a slight cough and did not want to give it to anyone. The DON stated CNA A should have worn goggles or a face shield when entering Resident #1's room and did not have an answer as to why she did not and was not aware she had not worn eye protection. The DON stated they had sufficient N95's for staff and sufficient face shields and eye protection for staff to use. The DON stated it was important to wear N95's and PPE appropriately to prevent contact with droplets. The DON stated the facility policy stated staff should be wearing their PPE. The DON stated CNA A did not follow the facility policy. The DON stated not appropriately wearing N95's or PPE could negatively impact residents because they would be at risk of catching an organism if CNA A was carrying an organism. Record review of CNA A's annual Personal Protective Equipment (PPE) Competency Validation revealed she was competent in donning PPE which included donning and doffing a mask/respirator and goggles or face shield. CNA A was also marked as competent in correctly identifying the appropriate PPE for use with standard precautions, contact, droplet and airborne precautions. Record review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and control Measures with a revised date of May 2023 and a updated date of July 2024, included a policy statement that stated, The facility follows infection prevention and control (IPC) practices recommended by the Centers of disease Control and Prevention to prevent the transmission of COVID-19 within the facility. The section titled Policy Interpretation and Implementation included the following verbiage, 1. The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention control plan. These measures include .f. implementing source control measures .h. implementing use of PPE for staff as indicated. 455923 Page 3 of 3