Health inspection·March 7, 2024

F 0880 with Gastroenteritis infection on 12/27/23 and resolved on 12/28/23; then again on 2/26/24. Further review revealed there were no other residents with same the same diagnosis during this time period. Level of Harm - Minimal harm or potential for actual harm Review of progress notes from December 2023 to February 2024 revealed the following: Residents Affected - Few *12/24/23 at 12:07 PM written by LVN E, indicated Resident #1 had lose stools and sent out to the hospital. *12/27/23 at 1440 (2:40 PM) written by LVN F, revealed a new order for Cefpodoxime related to salmonella infection. *1/9/24 at 2050 (8:50 PM) written by LVN G indicated Resident #1 received ABT. The MD indicated he did not re-test because Resident #1 did not have any more lose stools and he completed the ABT. Further review revealed Resident #1's family member mentioned Resident #1 was not getting better on the medication. *2/18/24 at 2128 (9:28 PM), revealed Resident #1 had signs and symptoms of nausea and diarrhea again. *2/20/24 at 13:43 (1:43 PM) written by LVN F, revealed Resident #1 did not have any lose stools. *2/21/24 at 1342 (1:42 PM) written by LVN F, revealed NP A assessed Resident #1, and Resident #1's family member requested IV therapy for dehydration and NP A agreed and provided an order. There was also new orders for Zofran (used alone or with other medications to prevent nausea and vomiting) and Loperamide (treat sudden diarrhea) to be administered until 2/29/24. Interview on 3/5/24 at 3:30 PM with the DON revealed NP A ordered a stool sample per protocol after Resident #1 had a few episodes of diarrhea upon admission. She stated the diarrhea subsided and then about 1 week later it started again. It was more persistent and lasted for about 4 to 5 days. The DON stated NP A ordered Resident #1 with a full treatment of antibiotics. She further stated the signs/symptoms cleared and then last week or the week before Resident #1 had diarrhea again. The DON stated Resident #1 was diagnosed with salmonella. She stated she learned most recently she was supposed to report it to the local state authority after she received a call from a representative from the local state authority. She was provided with a document with a list of reportable infections and Salmonella was on the list. The DON stated she had been the facility DON as of June 2023 and it was her first DON position. The DON provided the document and further stated it also reflected they should also report the incident to HHSC. She stated it would be the ADM who would report the incident. Interview on 3/5/24 at 4:35 PM with the ADM revealed she was responsible for reporting all reportable incidents to HHSC but did not know she had to report a positive infection for salmonella. She stated in the 20 years as an ADM she had never had experienced residents with Salmonella. Interview on 3/5/24 at 4:38 PM with CNA B revealed she had worked at the facility for 25 years and remembered Resident #1. She stated Resident #1 had a few episodes of diarrhea upon admission and learned he was diagnosed with an infection: food poisoning. She stated she did not remember Resident #1 being on isolation. Interview on 3/5/24 at 5 PM with the DON revealed she was the Infection Preventionist. She stated the purpose for reporting contagious infections to their local health authority would be for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 2 of 3 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 Residents Affected - Few accountability, tracking infections in the city that could spread and the local state health department would be able to provide guidance. She stated Resident #1 was placed on contact precautions; placed a sign on the door and a cart with PPE outside of his room. Interview on 3/5/24 at 5:27 PM with LVN C revealed she worked 2 to 10 PM for about 1 year. LVN C stated Resident #1 was diagnosed with Salmonella during February 2024. She stated Resident #1 was not placed on contact isolation but stated he was on contact precautions; standard precautions. However, there were no signs on Resident #1's door he was on contact precautions. Interview on 3/7/24 at 11:38 AM with the DON revealed she provided nursing staff a verbal order that Resident #1 was on contact precautions but she did not enter it into Resident #1's consolidated orders which would let nursing staff he was on contact precautions. The DON stated she should have entered the orders to ensure nursing staff that were not present at the time were aware and would take the necessary precautions. Interview on 3/5/24 at 12:41 PM with LVN D revealed she had worked in the facility for 33 years. She stated Resident #1 was tested after he started having diarrhea and was diagnosed with food poisoning, Salmonella. He was put on antibiotic. LVN D stated Resident #1 was on standard precautions but there was not a sign on the door reflecting he was on standard precautions related to an infection. She stated nursing staff protocol was to always use standard precautions. However, it was protocol required a sign to let nursing staff Resident #1 had an active infection. This also served the purpose to letting nursing staff to monitor and document on the resident's condition. Review of facility policy, Infection Prevention and Control Program, revised on 1/1/24 read: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precaution, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Surveillance: b. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of Texas Notifiable Conditions-2024 provided by the Texas Department of State Health Services revised 11/28/23 read Report all Confirmed and Suspected cases, Salmonellosis, including typhoid fever within 1 week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 3 of 3