Inspection·December 12, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 of 3 staff (Treatment Nurse) and 1 of 1 resident (Resident #1) reviewed for infection control. The facility failed to ensure the Treatment Nurse performed appropriate glove changes and hand hygiene between glove changes while performing wound care on Resident #1 on 12/12/25. This failure could place residents at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings included: During an observation on 12/12/25 at 10:07 a.m., the Treatment Nurse did not perform hand hygiene, applied clean gloves, entered Resident #1's room, cleansed the bedside table, laid down a barrier (a protective pad to keep wound care supplies clean), set her supplies on top of the barrier, and removed her gloves. The Treatment Nurse did not perform hand hygiene and applied clean gloves. The Treatment Nurse removed the dirty dressing from Resident #1's sacral area (triangular-shaped bone at the base of the spine that supports the upper body's weight while sitting), removed her gloves, did not perform hand hygiene, and applied clean gloves. The Treatment Nurse cleansed the wound to Resident #1's sacral area, did not change gloves and did not perform hand hygiene. The Treatment Nurse applied collagen powder (a powder that forms a protective gel and creates a moist environment to speed up wound healing for chronic wounds) to Resident #1's wound on her sacral area and covered with a bordered dressing (an absorptive dressing consisting of three layers). The Treatment Nurse did not change gloves or perform hand hygiene. The Treatment Nurse removed the sock from Resident #1's right foot and observed the wound/discolored area to Resident #1's right heel. The Treatment Nurse applied betadine to Resident #1's right heel. The Treatment Nurse removed her gloves, did not perform hand hygiene, gathered her trash, exited the room, disposed of her trash, got a clean blanket off the linen cart and handed it to a CNA (name unknown), and then performed hand hygiene. During an interview on 12/12/25 at 10:32 a.m., the Treatment Nurse said she had received training on wound care from the DON. The Treatment Nurse said she usually performed hand hygiene prior to entering a resident room and upon exiting a resident room. The Treatment Nurse said glove changes should be performed after removing a dirty dressing and when going from one wound to another. The Treatment Nurse said she did not routinely perform hand hygiene between glove changes. The Treatment Nurse said the importance of proper hand hygiene and glove changes was infection control. During an interview on 12/12/25 at 12:20 p.m., the DON said she expected staff to perform hand hygiene before providing care, during care, after care, and any time gloves were changed. The DON said gloves should be changed when going from a dirty area to a clean area, after every step in providing care such as removing dressing, cleansing a wound, and then putting the wound treatment and dressing on a wound, and when going from one wound to another wound. The DON said the importance of appropriate glove changes and hand hygiene was to prevent infections and cross contamination. Record review of the facility's Wound Care policy, 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: 675320 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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)