Health inspection·November 9, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections 1 of 1 facility reviewed for infection control. Residents Affected - Some The facility failed to clean and disinfect soiled shower chair in combined shower room A and B. The facility failed to clean and discard soiled wipes left on the floor in shower room C. This failure could place resident at risk of infection transmission. Findings included: Observation on 11/09/2024 at 10:30 AM revealed a combined shower room A and B shower chair had dried bowel movement on the top left seat and inside left corner of the shower chair. Observation on 11/09/2024 at 10:38 AM revealed shower room C had soiled wipes left on the shower room floor. Interview on 11/09/2024 at 11:44 AM with CNA A stated in combined shower room A and B it was dried bowel movement on the shower chair seat. CNA A stated in shower room C it was soiled wipes on the shower room floor. CNA A stated that she did not know who used the shower rooms last and it was expected to clean and disinfect the shower rooms after each use. Interview on 11/09/2024 at 12:23 PM with RN B stated she would not know who used the shower rooms last and did not clean the shower chair or pick up soiled wipes off the floor. RN B stated the expectations were for the CNAs to clean and disinfect the shower rooms after each use and in between residents. RN B stated it was unknown how long the shower chair was soiled or last used. RN B stated once wipes were used it was expected to be discarded in the personal hygiene trash bag ,tied up, and discarded. Interview on 11/09/2024 at 12:30 PM with the ADM stated it was expected for the shower rooms to be cleaned and disinfected after each use. The ADM stated it was unacceptable for the shower chair to be soiled and the soiled wipes to be on the floor of the shower rooms. The ADM stated not cleaning and disinfecting after each use could cause transmission of diseases and infections that may cause illness. Interview on 11/09/2024 at 1:24 PM with CNA C stated it was expected to disinfect and clean showers after each use. CNA C stated she had observed the shower chairs left uncleaned with feces. CNA C Page 1 of 2 675144 675144 11/09/2024 Avir at Burleson 600 Maple St Burleson, TX 76028

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she could not recall the dates when the showers were left unclean. CNA C stated she would just clean and disinfect the shower room once she noticed it not being cleaned and disinfected. Interview on 11/09/2024 at 1:43 PM with CNA D stated when she would shower residents, she often found feces left on the shower chairs and not being cleaned. CNA D stated she would clean and disinfect the showers and report it to a charge nurse(no specific name given). CNA D stated she was not sure who was not cleaning the shower chairs after each use. CNA D stated it was expected that staff would clean and disinfect the showers after each use. Interview on 11/09/2024 at 2:09 PM with ADON stated it was the staff's responsibility to make sure after each shower use that the shower area was clean. The ADON stated it was expected for the shower rooms to be cleaned and disinfected after each shower use. Interview on 11/09/2024 at 2:40 PM with CNA E stated she gave her resignation to the ADON on 11/08/2024 by email. CNA E stated she could no longer work there because the shower chairs aways had feces left on them and it was not cleaned. CNA E stated she would clean once she noticed but never knew who had left the shower chairs not cleaned. CNA E stated it was expected for the shower rooms to be cleaned after each use. Record review of the facility's Infection Prevention and Control Policy dated July 2024 reflected An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of the facility's Bathrooms Policy dated revised February 2020 Bathrooms, including showers, sinks, commodes, etc, are cleaned and disinfected daily in accordance with out established procedures. 675144 Page 2 of 2