Health inspection·October 24, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **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 four (Residents #1, #2, #3, and #4) of six residents and two (CNA B and CNA C) out of five staff in the facility reviewed for infection control practices and transmission-based precautions. Residents Affected - Some 1. The facility failed to ensure Residents #1 and #2 were separated after Resident #2 tested positive for COVID on 10/19/23, and Resident #1 did not. 2. The facility failed to ensure Residents #3 and #4 were separated after Resident #4 tested positive for COVID on 10/19/23, and Resident #3 did not. 3. The facility failed to ensure staff utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. An Immediate Jeopardy (IJ) was identified on 10/23/23 at 3:45 PM. While the IJ was removed on 10/24/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. The findings included: Review of Resident #1's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic obstructive pulmonary disease with acute exacerbation (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Review of Resident #1's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #1's quarterly MDS Assessment, dated 10/11/23, reflected she had a BIMS score of Page 1 of 9 675270 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 09 indicating moderate cognitive impairment. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Residents Affected - Some Review of Resident #3's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure (a condition where the lungs cannot provide enough oxygen), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior). Review of Resident #3's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #3's quarterly MDS Assessment, dated 07/26/23, reflected she had a BIMS score of 11, indicating moderate cognitive impairment. Review of Resident #3's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Review of Resident #2's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included 2019-nCov acute respiratory disease (COVID-19), alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), and cerebral infarction (a stroke). Review of Resident #2's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. Review of Resident #2's quarterly MDS Assessment, dated 08/31/23, reflected she had a BIMS score of 02 indicating severe cognitive impairment. Review of Resident #2's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #2's care plan, dated 08/31/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy Review of Resident #4's face sheet, dated 10/24/23, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack (a stroke), 2019-nCov acute respiratory disease (COVID-19), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). Review of Resident #4's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. 675270 Page 2 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #4's significant change in status MDS Assessment, dated 08/30/23, reflected she had a BIMS score of 13, indicating no cognitive impairment. Review of Resident #4's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #4's care plan, dated 07/13/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy . Observation on 10/23/23 at 8:15 AM revealed Residents #1 and #2 were in their rooms together. Resident #1 was not wearing a mask and was sitting in her wheelchair next to her bed a few feet from Resident #2 who was in her bed asleep and not wearing a mask. Observation on 10/23/23 at 8:16 AM revealed Residents #3 and #4 were in their rooms together. Resident #3 was not wearing a mask and was sitting in her wheelchair with her bedside table in front of her eating breakfast. Resident #4 was not wearing a mask and was sitting on her bed and was a few feet from Resident #3. Observation on 10/23/23 at 8:17 AM outside Residents #1, #2, #3, and #4's room revealed two three-drawer bins with PPE in them including gowns, gloves, and face shields. There was also a sign posted that read to see nurse before entering room. Observation on 10/23/23 at 8:18 AM revealed CNA B walked into Residents #3 and #4's room wearing only an N95 mask and gloves. CNA B walked into the room and went to Resident #3 to retrieve her breakfast tray, took the tray to the cart on the hall, walked back into the room and went to Resident #4. CNA B tried taking Resident #4's tray and Resident #4 told her she was not finished with her breakfast and did not want her to take it yet. CNA B took her gloves off and walked out of the room without performing hand hygiene. Observation on 10/23/23 at 4:10 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on. Observation on 10/23/23 at 4:20 PM of Resident #4 revealed she was sitting in her wheelchair in the doorframe of her room, making her perpendicular to Resident #3's bed where she was currently lying down. LVN D walked down the hall towards Resident #4 and asked/encouraged her to go back to her side of the room. Neither resident was wearing a mask. Observation on 10/23/23 at 4:25 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on and Resident #2 was currently yelling for staff to help her and the residents were having a conversation with each other about waiting for the staff to come and help Resident #2. In an interview on 10/23/23 at 8:20 AM with CNA B revealed both residents in the room she just left were positive for COVID-19 or had been exposed to it. CNA B said she only went into Residents #3 and #4's room to get their breakfast trays and wore her N95 mask and gloves. CNA B said what she wore in the room was fine so long as she was not changing the residents. CNA B said she did not feel like 675270 Page 3 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some putting on all the PPE like the gown just to retrieve a breakfast tray from the residents. CNA B said no one told her she should or should not make this choice, she did what she felt like she should do and that was what she did. CNA B said she did not want to continue talking about this and ended the interview. In an interview on 10/23/23 at 8:25 AM with the Activity Director revealed she provided a census and indicated a plus sign next to Residents #2 and #4. The Activity Director said that meant those two residents were positive for COVID-19. The Activity Director said since the roommates of those residents did not have a plus sign next to them it meant they were negative for COVID-19. The Activity Director confirmed that Residents #1 and #3 were negative for COVID-19 and each in a room with a positive for COVID-19 resident (Residents #2 and #4). In an interview on 10/23/23 at 8:30 AM with LVN D revealed she cared for Residents #1, #2, #3, and #4. LVN D said Residents #2 and #4 were positive for COVID-19 and their roommates Residents #1 and #3 were negative for COVID-19. LVN D said the residents were in the same room because there was no where else to move them without contaminating the new room if they did become positive for COVID-19 later on. LVN D said that was why the choice was made to keep them all in the same room. In an interview on 10/23/23 at 8:45 AM with the Administrator revealed the facility hired a new DON last week who was out of the building for a few days so she was acting as the facility's Infection Preventionist for now. The Administrator/IP said Residents #2 and #4 were positive for COVID-19. In an interview on 10/23/23 at 10:35 AM with LVN D revealed since she knew Residents #1 and #3 were negative for COVID-19 and were in the same room as Residents #2 and #4 who were positive for COVID-19 she always wore PPE when entering their rooms. LVN D said she already had an N95 mask on so she put on a gown, gloves, and a face shield when caring for the residents. LVN D said she tried to care for the COVID-19 negative residents first, performed hand hygiene, changed her PPE, and then cared for the COVID-19 positive residents next. In an interview on 10/23/23 at 10:52 AM with CNA B revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA B said she knew that when caring for Residents #1, #2, #3, and #4 that she was supposed to wear a gown, gloves, and a face shield. CNA B said she was supposed to care for the COVID-19 negative residents, which were #1 and #3, first and perform hand hygiene and change her PPE before caring for the COVID-19 positive residents, which were #2 and #4. In an interview on 10/23/23 at 11:01 AM with CNA C revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA C said while she was not assigned to Residents #1, #2, #3, and #4 she knew that Residents #2 and #4 were COVID-19 positive and Residents #1 and #3 were COVID-19 negative. CNA C said if she had to care for these residents she would treat them the same and wear full PPE including a gown and gloves. Observation on 10/23/23 at 11:25 AM of Residents #3 and #4 revealed there was a family member in their room and they were telling Resident #3 to stay on their side of the room so they did not also catch COVID-19. Resident #3 was observed standing in the middle of the room with her walker and Resident #4 was sitting in her wheelchair a few feet away. Resident #3 began to walk backwards and sat down on her bed. Neither resident was wearing a mask. Continuous observation on 10/23/23 at 11:56 AM of CNA B, CNA C, and LVN D passing trays to 675270 Page 4 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Residents #1, #2, #3, and #4's rooms revealed the following: Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Some CNA B was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #1 and #2's room to take Resident #1 her lunch tray. CNA B asked LVN D if she needed to change her gown before taking Resident #2's tray to her and LVN D told her yes. CNA B took off her gown and washed her hands inside the room. CNA B put on a new gown, face shield, and gloves. CNA B walked into the room and sat down next to Resident #2 to assist her with her lunch meal. CNA C was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #2 and #4's room to take Resident #4 her tray. CNA C took off her gown and gloves, did not wash her hands, and walked out of the room. CNA C put on new gloves, a gown, and a face shield. CNA C walked to Resident #3's bed and sat her lunch tray down. CNA C took off her gown, gloves, and face shield and washed her hands before leaving the room. LVN D was attempting to correct CNA B and CNA C in live time ensuring they were wearing the correct PPE and washing their hands but they were not listening. LVN D was visibly frustrated and ended up leaving the area saying she could no longer be a part of the situation. In an interview on 10/23/23 at 12:10 PM with CNA C revealed she could not remember what she did or did not do because there was too much going on all at once. CNA C said she thought she did everything right. In an interview on 10/23/23 at 1:15 PM with CNA B revealed she knew what she did wrong but did not want to specify. In an interview on 10/23/23 at 4:30 PM with LVN D revealed she had a conversation before the lunch meal service with CNA B and CNA C and went through what they needed to do and what PPE they needed to have on. LVN D said there were also signs posted on the outside of the doors to the residents' rooms both inside and outside. LVN D said she was not sure why CNA B and CNA C failed to put on the correct PPE and failed to perform hand hygiene properly. In an interview on the phone on 10/23/23 at 5:41 PM with Physician A revealed he was one of the doctor's treating residents at the facility. Physician A said he was aware the facility had experienced a COVID-19 outbreak and had positive residents. Physician A said he was last at the facility on 10/19/23 to check on residents and provide support to the facility. Physician A said he did not know there were both COVID-19 positive and negative residents together in the same room. Physician A said he would not advise the facility to cohort residents unless they were both positive for COVID-19. Physician A said he did not think it would be wise or allowed by CMS or the state of Texas to cohort residents if one was COVID-19 positive and the other COVID-19 negative. In an interview on 10/23/23 at 12:18 PM with the Administrator/IP revealed the facility had recently experienced an outbreak of COVID-19 beginning on 10/11/23 when LVN E tested positive. The Administrator/IP said she immediately began testing all residents and staff and found five positive 675270 Page 5 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents on 10/11/23, one positive resident on 10/12/23, and then four positive residents on 10/19/23. The Administrator/IP said Residents #2 and #4 were two of the four residents who tested positive on 10/19/23. The Administrator/IP said both residents #2 and #4 had roommates which were Residents #1 and #3. The Administrator/IP said based on a lot of times previously the roommates of positive residents test positive for COVID-19 the next day after being exposed so she did cohort the positive and negative residents (referring to Residents #1, #2, #3, and #4). The Administrator/IP said she felt it would be upsetting and detrimental to move the residents around especially the specific groups of roommates (referring to Residents #1 and #2, and #3 and #4). The Administrator/IP said she and the staff were trying to keep the residents apart in the rooms and use separate PPE when caring for them. The Administrator/IP said it would also have triggered a lot of other residents to have had to move rooms if they did separate the positive and negative COVID-19 residents since the facility did not currently have any empty rooms. The Administrator/IP said she looked at the CDC's recommendations to see what their isolation guidelines were and informed the local health department the facility had COVID-19 positive residents and staff. The Administrator/IP said she could not find any information from the CDC about cohorting residents and only saw information regarding isolation and quarantine periods. The Administrator/IP said she usually wanted to try and move residents and not cohort them together in the same room if one was COVID-19 positive and the other was COVID-19 negative but was not sure what the facility's policy was and would have to look at it first. The Administrator/IP said the purpose of cohorting residents correctly based on their COVID-19 status was to stop the spread of the infection. The Administrator/IP said the risk of residents not cohorted based on their COVID-19 status put them at risk of getting infected by COVID-19. The Administrator/IP said when caring for these residents staff should be putting on full PPE meaning a gown, gloves, and a face shield. The Administrator/IP said PPE was available outside the residents' rooms and there were signs posted for staff to follow that showed the order to put the PPE on. The Administrator/IP said the purpose of putting on the PPE was to prevent others from getting COVID-19 germs on them and spreading that to other residents. The Administrator/IP said the risk of staff not putting on the correct PPE while caring for COVID-19 positive residents was that they could spread the infection to other residents. The Administrator/IP said she expected staff to also perform hand hygiene when entering/exiting a resident's room or putting on/taking off their PPE. The Administrator/IP said the purpose of performing hand hygiene was to get the germs off their hands to not spread infection. The Administrator/IP said staff had been in-serviced on what PPE to wear when going into rooms and when to wash their hands or use hand sanitizer. The Administrator/IP said the nursing staff and management were monitoring staff to ensure they were following infection control practices and procedures correctly. Review of the facility's policy, titled COVID-19 Plan, revised 03/24/21, reflected the following: Suspected case(s) of COVID-19 in the Facility .only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection .For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available Review of the facility's Infection Control- Precautions- Categories and Notices policy, dated August 2020, reflected the following: .3. Standard Precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status .5. In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, or the 675270 Page 6 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some performance of procedures.) .b. Resident placement .place the resident in a private room, when a private room is not available, residents with the same infection with the same microorganism, but with no other infection may be co-horted Review of the facility's Hand Washing policy, dated August 2020, reflected: .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection .1. The use of gloves does not replace proper hand washing .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .before and after direct resident contact .before and after entering isolation precaution settings .after removing gloves Review of the CDC's website on 10/23/23 (accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Reflected the following Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated 05/08/23 .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection . The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing . Patient Placement .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Administrator was notified on 10/23/23 at 3:45 PM that an IJ situation was identified due to the above failures. The Administrator was provided the IJ template on 10/23/23 at 3:49 PM. The facility's plan of removal was accepted on 10/24/23 at 9:52 AM and included the following: 10/23/2023 Plan of Removal - F 880 Immediate Action Taken Resident Specific All residents tested for Covid 19 by rapid antigen card on 10/23/23 at 4:02 pm. All residents negative. All staff in facility tested on 10/23 and were all negative. All nursing staff currently on Staff inserviced regarding PPE usage at 12:00 pm by Administrator. Resident #[1] and # [3] (negative residents) moved to room [#] at 10/23/23 at 4:55 pm. 675270 Page 7 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 MD notified of the IJ on 10/23/2023 at 3:53 pm by Administrator, no new orders received. Level of Harm - Immediate jeopardy to resident health or safety Resident #[2] and Resident #[4] (positive residents) moved to room [#] on 10/23/23 at 5: All other staff in facility(including housekeeping, laundry, dietary) inserviced on PPE usage by Administrator. Residents Affected - Some System Changes Facility will ensure that positive and negative residents are not cohorted together in the same room. Education Administrator providing education to all staff regarding correct PPE usage for Covid Positive staff and and educated on not cohorting positive and negative residents together, and hand washing. All staff present in the facility were educated on 10/23/2023. Return demonstration will be performed on all staff in facility on 10/23. All Staff (including housekeeping, laundry, dietary) not present for the education will receive the education prior to their next shift with return demonstration on proper PPE usage and hand washing. Nurse consultant to educate Administrator on proper PPE usage and hand washing. Monitoring Residents are monitored daily for signs/symptoms of Covid while in outbreak. Staff will be monitored for correct PPE usage by Administrator/designee each day and logged on a monitoring tool. Staff will be monitored for correct hand washing/hand sanitizer usage by Administrator/designee each day and logged on a monitoring tool. On 10/24/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Monitoring observations on 10/24/23 at 12:15 PM revealed Residents #1 and #3 were in a room together and Residents #2 and #4 were in a room together. Positive and negative residents were no longer cohorted together in the same room. Monitoring observations on 10/24/23 from 12:20 PM to 1:11 PM revealed staff performing hand hygiene before/after entering/exiting a residents' room and before/after donning/doffing PPE. Staff were observed donning gowns, gloves, and a face shield before entering Residents #1, #2, #3, and #4's rooms to care for them. Staff were observed performing hand hygiene, doffing their PPE, and donning new PPE before interacting with another resident. Monitoring interviews were conducted on 10/24/23 starting at 1:11 PM and continued through 2:44 PM with the following staff from various shifts: CNA B, CNA C, CNA F, CNA G, CNA H, LVN D, LVN E, LVN I, LVN J, the Dietary Manager, the Activity Director, the Housekeeping Director, and the 675270 Page 8 of 9 675270 10/24/2023 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Administrator/IP. Staff knew that residents who were positive and negative for COVID-19 could not be in the same room together. Staff knew what PPE to wear when caring for a positive COVID-19 resident, in what order the PPE was to be put on and taken off, and when to perform hand hygiene. On 10/24/23, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 675270 Page 9 of 9