Inspection·September 1, 2023

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 designed to prevent the development and transmission of infection for one of two residents (Resident #1) observed for infection control. Residents Affected - Few The facility failed to ensure TCNA A performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk for infection. Findings include: A record review of Resident #1's face sheet, dated 09/01/23, reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with depression, malnutrition, and muscle weakness. A record review of Resident #1's Comprehensive MDS assessment , dated 07/21/2023, reflected Resident #1 had a BIMS of 11 which indicated Resident #1's cognition was moderately impaired. Resident#1 functional status was total dependence and assistance of two-person physical assistance with bed mobility and transfer. Observation on 09/01/23 at 02:30 PM revealed TCNA A provided incontinent care to Resident #1. TCNA A had gloves on and brief open. TCNA A proceeded to clean Resident #1's genital area with wipes and turned resident and cleaned stool off Resident #1. TCNA removed gloves but did not do hand hygiene. TCNA A put clean brief under Resident #1. TCNA A and CNA B turned resident to pull clean brief under resident and clasped clean brief. Resident #1 stated she had another bowel movement. TCNA A and CNA B unclasped the brief. TCNA A cleaned stool off Resident #1 for a second time. TCNA did not remove gloves or do hand hygiene. TCNA A placed a second clean brief under Resident #1. TCNA A and CNA B turned Resident #1 again to place clean brief and draw sheet under her. TCNA A grabbed a clean pillow and handed it to CNA B and then grabbed Resident #1's blanket to place on top of her. In an interview on 09/01/23 at 02:45 PM with TCNA A revealed that she does hand hygiene before patient care. She stated that she should have removed gloves and done hand hygiene each time she cleaned bowel movement to prevent infection. She stated I forgot because I was nervous. I am sorry. TCNA A states that she was trained on it recently. In an interview on 09/01/23 at 02:50 PM with CNA B revealed that she does hand hygiene before and after patient care. She stated after cleaning a bowel movement she would remove gloves and do hand hygiene to prevent spread of infection. (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: 455970 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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)