Health inspection·January 26, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 2 residents (Residents #3) reviewed for a notification of a change of condition, in that: Resident #3 was known to be covid-19 negative but roomed with Resident #4 who was known to be covid-19 positive. Facility failed to report to Physician that his patient Resident #3 was being roomed with a covid positive Resident #4. This deficient practice could place residents at risks of not having the physician contacted when they have a change of condition, and it could result in delay of medical treatment and hospitalization. Findings included: Record review of Resident #3's face sheet, dated 1/26/24, revealed a male resident with an admission date of 3/17/23 and diagnosis that included type 2 diabetes mellitus, muscle wasting, muscle weakness, and repeated falls. Record Review of the facility's covid-19 testing log dated 1/25/24 indicated Resident #3 was tested for covid on 1/21/24, 1/24/24, and 1/25/24 which all resulted as negative. Record Review of the facility's covid-19 testing log dated 1/25/24 indicated Resident #4 (roommate to Resident #3) was tested for covid on 1/21/24 (covid-19 positive), 1/24/24 (covid-19 negative) and 1/25/24 (cvodi-19 negative). Resident #4 was also notated as asymptomatic. During an interview on 1/24/24 at 3:20 PM the ADON stated that the reason Resident #3 (covid-19 negative) was in the room with Resident #4 (covid-19 positive) was because Resident #4 refused to be moved to the locked unit and Resident #3 refused to be moved from their room. She stated that was why they kept Resident #3 and Resident #4 in the same room. During an interview on 1/24/24 at 11:45 PM Resident #3 stated that he understood that he was in the same room as a resident who was covid positive, and the facility did offer him to go to another room, but he did not want to go. During an interview on 1/25/24 at 3:20 PM the ADON stated that she knew she called all the residents' physicians to let them know they had covid-19 in their building but could not find the notation on Resident #3 that his physician was informed. Page 1 of 6 675881 675881 01/26/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/26/24 at 11:00 AM Physician A stated that the facility only let him know about his patient Resident #3 staying in the same room as a covid-19 positive about two hours ago (approximately 9:00 AM). He stated the facility did let him know of covid-19 positive residents in the building on 1/21/24, but not that Residents #3 was sharing a room with one of them. He stated when the covid-19 positive resident was found on 1/21/24, he would have directly contacted the resident to let them know it was not a good idea and he would have suggested that the resident be moved to another room and directly suggest that guidance to the resident. Record review on facility's Change in a Resident's Condition or Status policy dated 11/2015 revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the residents medical/mental conditions and/or status. 1. The nurse supervisor/charge nurse will notify the residents attending physician or on-call physician when there has been. 675881 Page 2 of 6 675881 01/26/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

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 ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for 2 of 15 (Resident #1 and Resident #2) residents reviewed for infection control. Residents Affected - Some Three facility staff (MT, HA A, and HSKG) failed to follow the facility's infection prevention protocol for COVID-19 by failing to wear appropriate PPE. MT entered the hot zone with N95 mask and no other PPE. HA A did not wear appropriate PPE for the warm unit. HSKG did not wear appropriate PPE going into hot zone and shower room. Shower room was not sanitized after Resident #1, who was on isolation for exposure to COVID-19. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: Record review of Resident #1's face sheet, dated 1/26/24, revealed a female resident with an admission date of 12/10/20 and diagnosis that included dementia, anxiety, and type 2 diabetes mellitus. Record review of Resident #2's face sheet, dated 1/26/24, revealed a female resident with an admission date of 7/31/23 and diagnosis that included cellulitis of left lower limb congestive heart failure, and cirrhosis of liver. During an interview on 1/24/24 at 11:15 AM the ADON stated they had 15 residents on isolation in the facility. The ADON stated 8 were on the locked unit and 7 isolated to their rooms due to being recently covi-19d positive. She stated of the 15 residents on isolation none of the residents were covid-19 positive because they just had tested all residents that morning 1/24/24 and they were all negative but were staying on isolation for a few more days. She stated there were 3 employees out that were covid-19 positive, one being the DON. She stated that she has been testing all employees and residents every 3 days or if they are symptom based. Infection Control COVID-19 Employee Testing Log 1/16/24 to 1/19/24: 12 employees tested positive. Infection Control COVID-19 Resident Testing Log 1/18/24 to 1/25/24 17: residents tested positive (cumulative). Infection Control COVID-19 Resident Testing log On 1/24/24 mass testing of all residents was done, all residents that were previously positive now tested negative, resulting in no positives in the building at this time. 675881 Page 3 of 6 675881 01/26/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0880 Infection Control COVID-19 Resident Testing log Level of Harm - Minimal harm or potential for actual harm On 1/25/24 mass testing of all residents was done, Resident #1 and Resident #2 tested positive all other residents were negative. Residents Affected - Some During an observation on 1/24/2024 at 12:19 PM the MT was observed to be wearing an N95 mask. She entered the locked unit (hot zone (a section of a facility, where there is a high risk of contamination by patients with an infectious disease)) did not don any additional PPE (face shield/goggles, gown, and gloves). The Med Tech walked to the resident and handed him his medication cup which he put in his mouth by himself and then exited the hot zone without changing her mask or donning any additional PPE. During an interview on 1/24/24 at 12:25 PM PM the MT stated that she did not put PPE on because she saw the resident right on the inside of the hot zone door and it was quick and easy for her to hand him his medication and to get out rather than take all the time to put the PPE on. She stated she knows she is supposed to put all PPE but felt it was going to be really quick to just hand the medication to the resident. During an interview on 1/24/24 at 3:20 PM the ADON stated her expectations of PPE use, for hot zone areas or to enter a covid-19 positive or quarantine resident's room was to don all PPE which included a gown, gloves, mask, and face shield/goggles. She stated that her expectation was not only that all PPE be worn but be worn correctly, meaning no mask below the chin or face shields not covering face, and eyeglasses do not count as eye coverings or face shields. She stated all covid positive residents had signage on the door with the proper PPE to be down. During an observation on 1/24/24 at 4:10 PM revealed HA A was working on the warm unit. HA A did have a face shield in place, but it was not being worn correctly. The face shield was pulled up way above her forehead and was not covering her nose and mouth. HA A was also wearing a KN95 mask. The KN95 mask was also being utilized incorrectly and was observed as being pulled below her chin and was not covering her mouth or nose. HA A was in the hot zone with covid positive residents all around her, residents were not wearing mask. During an interview on 1/26/24 at 11:20 HA A stated that she should have been wearing everything properly on the hot zone. She stated it just gets hot and she gets to working and has to breath so she will lift the face shield or mask sometimes to breath. She stated she thought she only need to put gown and gloves on while interacting with the residents not just on the hot zone. HA A stated was in the hot zone with covid positive residents all around her, residents were not wearing mask. During an observation on 1/25/24 at 11:15 revealed Resident #1, who was on isolation, due to exposure (been within 6 feet of someone with COVID-19 for at least 15 cumulative minutes or more over a 24-hour period) was observed sitting, in his wheelchair, with no mask on, outside of the shower room, on hallway 100. Resident #1 was waiting to take a shower. The shower room was opened, Resident #1 entered the shower room and asked staff to set up the shower. No sanitation or cleaning was performed near the shower room or where Resident #1 was sitting in the hallway, following this observation. Resident #1 exited the shower at 11:50 AM, with no mask on, and went back to his room. The distance from the shower room to Resident #1's room was roughly 30 feet. No sanitation was done in between going from any of the covid-19 positive to covid -19negative rooms. During an observation on 1/25/2024 at 12:24 PM, revealed the HSKG was observed wearing an N95 mask 675881 Page 4 of 6 675881 01/26/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when she began to don a gown and gloves, prior to entering Resident #1's room; COVID-19 quarantine room. The HSKG was not wearing a face shield or goggles when she entered the room. The HSKG exited the COVID-19 quarantine room without a gown, gloves, face shield or goggles. The HSKG did not discard her N95 mask or obtain a new one after exiting the room. During an interview on 1/25/24 at 1:15 PM HSKG stated that she was not told that a face shield or goggles needs to be worn when going into covid positive room, she stated she thought her glasses were enough. She stated she was never told that glasses were not proper PPE. She stated that she will make sure to put a mask or goggles on from this point on. Attempted to contact MD on 1/25/24 at 2:45 PM, no answer, left message. During an observation on 1/25/24 at 2:15 PM revealed the ADON tested Residents #1 and Residents #2 for covid-19. The ADON was in full PPE and technique was good while in the residents' rooms to test for covid-19. Upon testing, it was found that both residents were covid-19 positive. After testing positive Resident #1 was moved to locked unit (hot zone) and Resident #2 was quarantined to room. Attempted to contact the Medical Director on 1/25/24 at 2:45 PM, no answer, left message. Record reviews the covid-19 positive tracking log, dated 1/25/24, of all residents that tested positive (17) revealed all residents were asymptomatic or mild symptoms that included, headache, runny nose, or tiredness. During an interview on 1/26/24 at 3:15 PM the Administrator stated that the only way covid-19 got in the building was by staff or visitors. He stated they had to use a lot of agency nursing, but staffing had been good during the entire process. He stated this outbreak was difficult because there would be one or two employees here or there, but this was out of nowhere were a bunch of employees and residents all tested positive at once. During an interview on 1/26/24 at 2:45 PM the ADON stated in the absence of the DON she would be the infection preventionist. She stated that if PPE was not being worn properly it would put the residents at risk of getting covid-19. She stated she knew some of her staff were not the best about wearing their PPE and she had talked to them about this. Record review of the facility's Covid-19 Prevention, Response and Reporting policy dated 5/11/23 revealed: 11. Personal Protective Equipment Considerations: i. NIOSH-approved particulate respirators with N95 filters or higher used for: 1. All aerosol-generating procedures 2. in other situations, where additional risk factors for transmission are present, such as resident is unable to use source control and the area is poorly ventilated. They may also be considered if healthcare-associated SARS-CoV-2 transmission is identified and universal respirator used by HCP working in affected areas is not already in place. 3. Resident care encounters or in specific units or areas of the facility at higher-risk for 675881 Page 5 of 6 675881 01/26/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0880 SARS-CoV-2 transmission Level of Harm - Minimal harm or potential for actual harm ii. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all resident care encounters. Residents Affected - Some 675881 Page 6 of 6