Health inspection·August 24, 2022

F 0578 addressing the resident's code status. Level of Harm - Minimal harm or potential for actual harm Review of Resident #39's current Care Plan dated as created [DATE] revealed resident has chosen DO NOT RESUSCITATE status. Residents Affected - Few During an interview on [DATE] at 10:40 a.m. the MDS Coordinator said she had spoken with Resident #39 and the resident had told her she had a DNR status. The MDS Coordinator said that information was in the hospital paperwork, and that was why she put that information on the resident's care plan. During an interview on [DATE] at 8:50 a.m. the ADON said Resident #1's code status was a Full Code based on a Full Code order dated February 2022 on admission. She said the facility did not have a signed DNR for him and said she had told the resident's family member that the facility needed a signed DNR. The ADON said she knew the resident's family had made arrangements for him regarding his code status. She said she believed the resident's family member had signed an OOH-DNR on [DATE], and the doctor put the order in the electronic record. The ADON said she would say there was some confusion regarding Resident #1's code status. She said the DON looked at the MD orders when they were put in the system, and the DON and herself were both responsible for looking back at the doctor's orders. The ADON said Resident #39 had a code status of Full Code. She said if the facility did not have a signed DNR, the resident was automatically a Full Code. She said she did not see the code status addressed in Resident #39's physician's orders, and a resident's code status should be addressed in the admission orders. She said the staff member who took report and did the admission paperwork had the responsibility to make sure a resident's code status was addressed. She said the facility did not accept OOH-DNR's, and Resident #39 would need to sign a DNR form. The ADON said that oversight was her responsibility, and as the ADON she tried to look at every new admission to follow-up on this. The ADON said a potential problem with a resident's code status not being accurate in the medical record could be confusion if the resident were to go into cardiac arrest. The ADON said if the resident were to go into cardiac arrest, the staff would have to perform CPR if there was not a document indicating they were a DNR. She said if a resident had a DNR wish, that (receiving CPR) would be a problem. An interview with the DON on [DATE] at 9:28 a.m. revealed the MD told her he had written the DNR order on [DATE] for Resident # 1 because it had been discussed; she said Resident #1 was confused, and officially Resident #1 was a Full Code. She said she could understand the confusion regarding resident's code status in the EHR. She said they were trying to get witnesses to sign the DNR document and had not been aware that it had not been completed. She said the facility did not accept OOH-DNR's, they were not valid at the facility, so a resident was a Full Code until a status was entered and the facility had the necessary paperwork. The DON said Resident #39 was a Full Code. She said the resident's code status was missed on the admission paperwork, and until the paperwork was there, a resident was a Full Code. The DON said the facility had a remote SW who usually addressed the resident's code status. The DON said since the SW worked part-time, she would say everybody had responsibility to ensure a resident had an accurate code status documented. She said the IDT team should be looking at the issue as they reviewed a resident's paperwork. The DON said a potential problem with a resident's code status not being accurately addressed could be the staff possibly performing CPR on a resident that didn't want it, and the resident's wishes would not be met. Review of the facility's policy titled Advance Directives, dated [DATE], revealed .The facility and company will recognize each patient's/resident's right to self-determination and their right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation (CPR), and the right to execute (or not execute) advanced medical directives such as Living (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 2 of 5 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0578 Level of Harm - Minimal harm or potential for actual harm Wills, agent designations, do-not-resuscitate directives, etc.Upon admission to the facility, the Admissions Coordinator will .Interview each patient/resident OR their legal representative/family members to determine whether or not the patient/resident has executed an advance directive of any type Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 3 of 5 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 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 establish and 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 one (Resident #2) of one resident observed during incontinent care. Residents Affected - Few CNA A failed to perform hand hygiene during incontinent care for Resident #2. This failure could place all residents and staff at risk for cross contamination and infection. Findings included: Review of Resident #2's Face Sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebrovascular disease (disorders in which an area of the brain is affected by damage to the cerebral blood vessels), glaucoma (an eye disease that results in damage to the optic nerve resulting in vision loss), anxiety, depression, diabetes (high blood sugar) and hypertension (high blood pressure). Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed she required extensive assistance with bed mobility and was frequently incontinent of bladder and bowel. The resident's assessment revealed a BIMS score of 14, indicating intact cognition. Review of Resident #2's current Care Plan, dated Last Care Conference 07/13/2022, revealed problem areas including Urinary Tract Infection, Urinary Incontinence and Bowel Incontinence. Observation of incontinent care provided to Resident #2 on 08/23/2022 at 11:45 a.m. by CNA A revealed the following: CNA A washed her hands and applied 2 sets of gloves. CNA A pulled the residents wet brief down and wiped the resident's perineal area from front to back, using one swipe per wipe, discarding the wipe, and repeating several times. The resident turned to her left side independently, and CNA A wiped the resident's buttock area from front to back, using one swipe per wipe, discarding the wipe, and repeating several times. CNA A removed her outer pair of gloves. CNA A placed a clean brief under the resident's left hip and applied a barrier cream to resident's buttock area. CNA A removed her gloves and donned a new pair of gloves. CNA A removed the wet brief from under the resident, removed her gloves and donned a new pair of gloves. CNA A positioned a clean brief underneath resident and the resident turned onto her back. CNA A attached the clean brief, removed her gloves, and washed her hands. During an interview with CNA A on 08/23/2022 at 11:55 a.m. CNA A said she had double-gloved at the beginning of the peri-care procedure because she had ripped a glove when donning the first pair. CNA A said she had large hands, and that caused the glove to rip during donning of the gloves. CNA A said she should have sanitized her hands after removing her gloves during the procedure and said a potential problem with not sanitizing her hands was she could transfer bacteria and/or germs to another surface, such as a hard surface, the resident or herself. Interview with the DON on 08/24/22 11:30 a.m. revealed her expectation of peri-care provided to a resident involved the staff member washing their hands and donning gloves at the start of the procedure and changing gloves when going between dirty and clean areas. The DON said when gloves were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 4 of 5 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 changed, hand sanitizer should be used if the hands were not visibly dirty, and hands should be washed at the sink if the gloves were visibly dirty. She said after 3 cycles of changing gloves and using hand sanitizer, staff needed to wash their hands. The DON said there was not an expectation of using 2 pairs of gloves. She said all staff had been in-serviced on hand hygiene during incontinent care on 08/23/22, and infections and possible UTI's were potential problems when proper hand hygiene was not done during incontinent care. Review of the policy titled Handwashing/Hand Hygiene, dated March 2020, revealed This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands .or complete hand hygiene with an alcohol-based hand rub .After removing gloves .The use of gloves does not replace handwashing/hand hygiene FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 5 of 5