Inspection·April 23, 2025

F 0812 slaw, pork steak, cheese sauce and bacon from the cooler and discarded them. Level of Harm - Minimal harm or potential for actual harm Record review of an undated facility policy on Food Storage indicated: .2. Refrigerators .d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Residents Affected - Some The dietary manager was on sick leave and could not be interviewed regarding the oversight of the dietary kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 2 of 4 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 675011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksonville 305 Bonita St Jacksonville, TX 75766 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)

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 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 1 of 4 residents, (Resident #35) reviewed for Enhanced Barrier Precautions. Residents Affected - Few RN D failed to put on a gown prior to performing an aseptic procedure of draining the peritoneal cavity with a surgically inserted peritoneal catheter. This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included: Record review of a face sheet dated 04/23/2025 indicated Resident #35 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included, congestive heart failure, chronic kidney disease, ascites (a buildup of fluid in the abdomen), atrial fibrillation (an irregular and rapid heart rhythm), end stage heart failure, gastro-reflux disease, and anxiety disorder. Record review of the quarterly MDS dated [DATE] noted Resident #35 had a BIMS score of 11 which indicated moderate cognitive impairment. He was receiving hospice services and had a peritoneal dialysis catheter inserted. Record review of Resident #35's physician orders indicated an order dated 03/26/2025 1. Aseptic dressing change performed with each drainage of port by hospice nurse. 2. Hospice nurse to drain patient's port and report drainage amount to facility. During an observation and interview on 04/22//2025 at 9:15AM, RN D (hospice nurse) was in the process of performing drainage of Resident #35's Aspira peritoneal drain. The peritoneal drainage process was observed. During the observation it was noted RN D had not donned a PPE gown and only had protective gloves on. After leaving the resident's room, the Enhanced Barrier Precautions (EBP) sign posted on Resident #35 door was noted and PPE supplies were stocked in hallway. During an interview after the procedure RN D said she did not don the PPE gown because she normally just wore gloves for the procedure. She said she had seen the EBP sign posted on Resident # 35 door but had not thought to don the PPE gown. Record review of the progress notes for Resident #35 dated 04/22/2025 at 9:27AM indicated, hospice nurse drained 2000ml fluid from port, abdomen measurement is 47 ml., and changed dressing as ordered. Documented by LVN C. Record review of the progress notes for Resident #35 dated 04/18/2025 at 12:15PM indicated, hospice nurse came and drained fluid using resident abdominal port, drained 2900ml. no complaint during fluid drainage or after completion. Record review of the progress notes for Resident #35 dated 04/14/2025 at 10:26AM indicated, a hospice nurse came and drained 3075ml of fluid from abdominal port area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 3 of 4 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 675011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksonville 305 Bonita St Jacksonville, TX 75766 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/22/2025 at 01:20 PM, LVN B said, she understood that EBP stood for Enhanced Barrier Precaution and had to do with infection control. She said EBP meant staff were supposed to wear a mask, gown, and gloves when handling catheters and wounds. LVN B reviewed the EBP sign on Resident #35's door and LVN B, said that a gown and gloves were to be used during high-contact resident care activities. LVN B said the staff had received in-services on infection control and EBP. Residents Affected - Few During an interview on 04/22/2025 at 01:40 PM, LVN C said, she understood that EBP stood for Enhanced Barrier Precaution, and it had to do with infection control. She said EBP meant staff were supposed to wear a mask, gown, and gloves when handling catheters and wounds. LVN C reviewed the EBP sign on Resident #35's door and LVN C verbalized understanding, saying that a gown and gloves were to be used during high-contact resident care activities. LVN C said the staff had received in-services on infection control and EBP. During an interview on 04/22/2025 at 03:30 PM, the DON said she was the Infection Preventionist for the facility. She said she expected the nurses to follow the facility's policies on infection control and prevention including the policies on EBP. The DON said, the hospice agencies were responsible for educating the hospice nurses on Enhanced Barrier Precautions. She said, she expected the hospice' s nurses, and the staff members to follow the guidelines of EBPs to reduce the risk for transmission of infection. The DON said the Charge Nurses reports and post Enhanced Barrier Precaution signs on residents' doors that had met the EBP criteria for the facility's staff, and hospice staff providing direct care. The DON said the purpose of EBP was to reduce the risk of spreading infection. The DON said RN D should have put on a gown prior to performing drainage of Resident # 35 Aspira drainage system:(a tunneled long-term catheter used to drain fluid from the pleural or peritoneal cavity) peritoneal catheter. A record review of the facility's policy dated 04/1/2024 and titled Enhanced Barrier Precautions indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). A record review of the facility's policy dated, July 2024, title Infection Prevention and Control Program indicated the following: The facility's infection control policies and practices are intended to facilitate, maintain a safe, sanitary, comfortable environment, help prevent, and manage transmission of diseases and infections. The objectives are to establish guidelines for implementing Isolation Precautions, availability and accessibility of supplies and equipment necessary for Standard and Transmission -Based Precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 4 of 4