Inspection·August 22, 2023

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of two residents reviewed for infection control practices in that: Residents Affected - Few CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 02/04/21, revealed a 70- year- old male admitted to the facility on [DATE] with diagnoses including muscle weakness, muscle wasting and atrophy, contracture of muscle, hemiplegia (partial or total paralysis) and hemiparesis (slight weakness) dementia, and diabetes mellitus. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 08/15/23 revealed he had bowel and bladder incontinence related to urinary incontinence. The goal stated Resident will be maintained in a clean, dry state and prevent complications of incontinence by checking and changing resident at regular intervals. Observation of incontinence care for Resident #1 on 08/21/23 at 4:09 p.m. revealed CNA A did not wash her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. She made 6 strokes of clean with same soiled wipe. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A again, did not wash her hands before exiting Resident #1's room. In an interview on 08/21/23 at 4:20 p.m. with CNA A, she revealed she should have washed her hands before starting care and changed her gloves during care. CNA A also revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she (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: 675522 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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)