Health inspection·November 25, 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 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 (Resident #1) of 5 residents observed for infection control practices. CNA B performed Resident #1's catheter care without placing a gown for EBP. This deficient practice could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old male resident admitted to the facility originally on 3/03/2022 and readmitted on [DATE] with diagnoses to include urinary tract infection with onset date of 9/17/2025, benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate gland that causes urinary issues). Record review of Resident #1's clinical record revealed his last full MDS was a quarterly completed 9/01/25 listing him with a BIMS of 9 indicating he was moderately cognitively impaired, he had a functionality of requiring set-up/clean-up for most of his activities of daily living, and he did not require a catheter at that time. Record review of Resident #1's care plan with admission date of 9/17/25 revealed the following: Resident has a bladder disorder requiring foley catheter (a flexible tube inserted into the blader through the urethra to drain urine) and is at risk for UTI. During an observation on 11/25/2025 at 10:11 AM CNA B performed catheter care for Resident #1. CNA B was noted observing the sign posted on Resident #1's door for EBP while placing gloves before entering the resident's room. This surveyor noted a PPE station placed on top of the unoccupied roommate's dresser. CNA B proceeded to perform catheter care to include cleaning the urinary tube, the resident peri and rectal area, and placing a new brief before replacing Resident #1's shorts and covers and ensuring he was comfortable. She then performed her final hand hygiene, gathered the used supplies, and exited Resident #1's room. CNA B never placed a PPE gown to maintain EBP and prevent contamination. During an interview on 11/25/2025 at 10:25 AM CNA B reported that Resident #1 should be on EBP because he has a catheter and stated, That was my mistake. I am used to them having a PPE station outside their room and I just missed the sign on his door. CNA B reported she did not see the PPE station inside Resident #1's room. CNA B stated, I know better. CNA B reported that she had been trained on EBP by the ADON who was no longer the infection control officer and that she (CNA B) was not sure who the current infection control officer was because they have had several management changes recently. CNA B reported that if EBP was not followed then they could get urine on themselves and could spread infection. During an interview on 11/25/2025 at 10:58 AM the DON reported that the facility has a new ADON that was currently completing the infection control training, that the previous ADON was no longer available to do the training. The DON reported that she expects her staff to place the proper PPE like a mask and gown when EBP was needed such as with catheter care. The DON reported that if the proper PPE was not used with EBP, then cross contamination would occur, and staff could carry infection from one resident Residents Affected - Few (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: 675055 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 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)