Health inspection·March 1, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm immediate needs shall be developed for each resident within 48 hours of admission. Policy interpretation stated in part: the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675871 If continuation sheet Page 2 of 4 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 675871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Comfort 615 Faltin Ave Comfort, TX 78013 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** 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 1 of 4 residents (Resident #10) reviewed for infection control. Residents Affected - Few The facility failed to post a sign on Resident #10's door to indicate she was on Contact Isolation (any of the techniques used in addition to standard precautions that decrease the likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items, e.g., methicillin-resistant Staphylococcus aureus). This deficient practice could affect staff, residents, and visitors who may enter Resident #10's room without the appropriate PPE and expose them to infection. The findings included: Record review of Resident #10's electronic face sheet (undated) reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: partial intestinal obstruction (happens when the intestines are partially blocked), toxic encephalopathy (neurologic disorder caused by exposure to toxic substances that damage the brain), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), methicillin resistant staphylococcus aureus infection (a type of bacteria that's resistant to a number of widely used antibiotics), and unspecified site, carrier or suspected carrier of methicillin resistant staphylococcus aureus (may be a carrier of the bacteria and can spread or transmit the bacteria to others). Record review of Resident #10's quarterly MDS assessment with an ARD of 02/23/2024 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She could understand and be understood. She required extensive assistance with her ADL's. Record review of Resident #10's comprehensive care plan revised 02/29/2024 reflected Problem, has a pressure ulcer infection on sacrum, Approach, use principles of universal/standard precautions for contact precautions per facility policy. Record review of Resident #10's physician orders dated 02/29/2024 reflected Pt to have contact isolation due to positive MRSA to nares until her ABT therapy done in 10 days. Special Instructions: Pt to maintain isolation status x 10 days. Start dated 02/26/2024. Observation on 02/28/2024 at 10:00 a.m. of Resident #10's door revealed she had a bin sitting outside against the wall with masks, gloves, and gowns in the drawers (PPE). There was no sign on her door. Observation on 02/29/2024 at 08:00 a.m. of Resident #10's door revealed she still had a bin outside of her door, and there was no isolation sign posted. In an interview on 02/29/2024 at 09:30 a.m. with the DON, she stated she informed the staff to set up isolation for Resident #10 when she returned from the hospital on [DATE] and the positive MRSA nasal swab was noticed in her lab work. She stated that staff who collaborated with the resident were informed she was on contact isolation. She stated there should have been a sign on Resident #10's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675871 If continuation sheet Page 3 of 4 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 675871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Comfort 615 Faltin Ave Comfort, TX 78013 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 door which indicated she was on contact isolation. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/29/2024 at 1:24 p.m. with C NA A, she stated she was informed that Resident #10 was on contact isolation, but there was no sign on the door. She stated the PPE was available and they wore a gown and gloves when they collaborated with the resident. Residents Affected - Few In an interview on 02/29/2024 at 1:30 p.m. with LVN B, she stated she was informed that Resident #10 was on contact isolation, but that a sign was not on the door because of HIPAA rules. Record review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions revised January 2012 reflected 8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675871 If continuation sheet Page 4 of 4