Inspection·February 22, 2024

F 0552 making, short-term and long-term memory loss. Level of Harm - Minimal harm or potential for actual harm Goal: The resident will maintain current level of cognitive function through review date. Residents Affected - Some Intervention: Administer medications ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #21's medication profile dated 10/13/23 indicated in part: Zoloft 50 milligrams, give 1 tablet by mouth once a day for anxiety. Record review of Resident #21's clinical records revealed no consent on file. Record review of Record review of Resident #35's face sheet revealed admission date of 10/06/21 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus, dysphagia (impairment of speech), anxiety disorder (severe, ongoing anxiety that interferes with daily activities), end stage renal failure disease(the stage when kidneys can no longer function on their own). She was [AGE] years of age. Record review of Resident #35's quarterly MDS, dated [DATE], indicated he had a BIMS score of 15, which indicated he was cognitively intact. The MDS also indicated Resident #35 was receiving antianxiety and anti-depressant medications. Record review of Resident #35's care plan indicated, in part: Focus: resident has diagnosis of depression. Goal: resident will have fewer episodes of depression. Intervention: administer medications as ordered, monitor labs, report abnormal labs to physician. Focus: The resident uses anti-anxiety medications alprazolam related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Record review of Resident #35's medication profile dated 12/24/22 indicated in part: Paxil 20 milligrams 1 tablet by mouth once a day for major depression disorder. Xanax 0.25 milligrams 1 tablet by mouth on Monday, Wednesday and Friday before dialysis. Record review of Resident #35's clinical records, revealed the no consent on file. Interview on 02/22/2024 at 11:35 AM, the DON stated that consents are obtained by the receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 2 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurse ,by ensuring the resident understands the details of the consents. If not, we have residents' responsible party come in to sign the consent. If it is a verbal consent, we have a hard copy obtained later. We obtain consents for wound care, eye care, dental, any outside, psychotropic medications and anti-psychotics, if the facility needs to reach out to the family to ensure consent a consent is signed. In this case, it is possible that we did not obtain a hard copy of the consents. The DON stated they are going to implement obtaining and keeping hard copies of consents and upload them to ensure accuracy of documentation. Record review of the facility's policy revised December 2016, titled Antipsychotic Medication Use indicated, in part: Residents/ responsible party will be notified of physician recommendations for psychotropic/ pharmacological interventions and consent to use the medication as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 3 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 92 days in July 2023 - September 2023 Residents Affected - Some The facility had no Registered Nurse coverage on dates 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. This failure could affect all residents and put them at risk of their care not being overseen properly. The findings were: Record Review of the facility's time sheets from July 01, 2023- September 30, 2023 - on 02/22/2024 at 01:00 PM revealed there was no Registered Nurse coverage on 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. During an interview on 02/22/2024 at 01:21 PM with the Director of Nurses confirmed there was no RN coverage for the date listed above. The DON stated the facility has been trying to hire new RNs by having competitive pay, sign on bonuses and benefits. The DON stated the facility has started to use agency nurses, but it is still hard to have consistency regarding RN coverage even with the agency staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 4 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms inspected for medication storage. The medication rooms had an expired Tuberculin (TB) vial medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 02/20/24 at 03:12 PM the medication room was inspected with LVN C present. There was a small refrigerator that contained several medications to include an open box that contained a 5ml vial that contained Tuberculin. The date on the box indicated it was opened on 12/22/23. The box indicated Discard opened product after 30 days. LVN C said she was an agency nurse and was not sure who was responsible for making sure expired medications were removed from the medication room. LVN C said she had not noticed the TB medication had expired. During an observation and interview on 02/21/24 at 11:10 AM the DON was made aware of the expired TB vial in the medication room. The DON said each nurse was responsible to make sure they dated the TB vial when it was opened and disposed of it when expired. The DON said there was no one assigned to check the medications in the medication room. The DON said if an expired TB was used it could cause a false reading. During an interview on 02/22/24 at 02:10 PM the Administrator was made aware of the expired TB vial observed in the medication room. The Administrator said if that medication was used it could lead to false reading or not be effective. The Administrator said the failure probably occurred because the staff was not paying attention and did not notice the TB was expired and should have been disposed. Record review of the facility's policy titled Labeling of medication containers dated April 2007 indicated in part: Policy statement -All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information such as: The expiration date when applicable and directions for use. Label for each floor's stock medications shall include all necessary information such as the expiration date when applicable. Record review of the Tuberculin Purified Protein Derivative Tubersol manufacture pamphlet dated April 2023 indicated in part: A vial of Tubersol which has been entered and in use for 30 days should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 5 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts ( Hall 100 nurse medication cart) reviewed for medication storage and failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure the hall 100 nurse medication cart did not contain expired insulin pens and had open dates after they were put into use. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. This failure failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications and could place the facility at risk of drug diversion and access to medications. Findings include: During an observation and interview on 02/21/24 at 11:02 AM LVN C was in the process of checking resident's blood sugars. LVN C had a caddy on the medication cart for hall 100 in which she carried several insulin pens. There was a total of 6 pens that did not have an open date and 1 that had an expired date. LVN C said she had not noticed that the pens were not dated when opened. LVN C said she worked for an agency, so she did not always work at this facility. During an observation and interview on 02/21/24 at 11:10 AM the DON was shown the 7 insulin pens. The DON said the insulin pens were supposed to be dated when opened and disposed of when expired. The DON said it was each nurse's responsibility to write an open date on the pens when they opened them. The DON said there was no one single person assigned to monitor the insulin pens and make sure they were dated. The DON said that they were going to have to assign someone to monitor this. The DON said if a resident received an insulin that had no expiration date or had been expired then there was a possibility the resident did not receive the therapeutic effect. The DON said the failure occurred because no one was monitoring to see that insulin pens were dated when opened or disposed of when expired. During an observation and interview on 02/21/24 at 02:44 PM the discontinued controlled medications in the DON's office with the DON present was inspected. The medications were kept in a large cabinet which was kept locked. The DON opened the cabinet and inside the cabinet were 7 blister packs that contained controlled medications. The medications consisted of Lorazepam (Antianxiety Agent - Benzodiazepines), Hydrocodone (Narcotic pain medication) and Tramadol (Opioid pain medication). These medication were not kept in the second container that had the second lock. The DON said the medications belonged to a resident that had recently expired and the medications were placed in the cabinet and not in the second container so it was her fault. The DON said if the medications were not kept behind 2 locks, then there was a chance of an unauthorized person taking the medications which could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 6 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0761 lead to a drug diversion or ingestion of the medications. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/22/24 at 02:12 PM the Administrator was made aware of the undated and expired insulin pens observed during medication pass and the discontinued control medications not kept behind 2 locks in the DON's office. The Administrator said staff were supposed to date the medications when opened or discard them after they expired or else they could not be as effective as indicated. The Administrator said the failure probably occurred because the staff did not pay attention and did not disposed of the expired medications or dated them when opened. The Administrator said the discontinued controlled medications were supposed to be kept behind 2 locks as their protocol indicated. The Administrator said the DON probably got distracted and did not place the discontinued control medications behind 2 locks. Residents Affected - Some Record review of the facility's policy titled Labeling of medication containers dated April 2007 indicated in part: Policy statement -All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information such as: The expiration date when applicable and directions for use. Label for each floor's stock medications shall include all necessary information such as the expiration date when applicable. Record review of the facility's policy titled Medication storage- controlled medications storage dated 01/2023, indicated in part: Medications included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 7 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: Residents Affected - Many 1.The facility failed to label and date food items. 2.The facility failed to discard expired food items. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 02/20/2024 at 11:30 AM of the refrigerator revealed: Red gelatin dated 2/11/24, shelf life 3 days. Peanut butter and jelly mixture dated 2/16/24, shelf life 3 days. 5 pounds of ground beef in plastic zip lock bag, unlabeled, undated, no use by date. 20 corn tortillas in asealed bag unlabeled, undated no use-by date. 20 flour tortillas in a sealed bag unlabeled, undated, no use-by date. Observation on 02/20/2024 at 11:45 AM of dry pantry revealed: 10 oz sprinkles unlabeled undated, no use-by date. 16 fluid oz bottle of red food coloring expired 10/02/2020. 1 gallon of Karo Syrup expired 02/12/2022. 1 pound bag potato chips expired 12/2022. Interview on 02/22/24 at 09:16 AM [NAME] A stated that all food in the refrigerator should be labeled. She stated her shift starts at 6:00AM, she is busy prepping meals and must have missed those items. Interview on 02/22/24 at 09:44 AM the DM stated the left-over storage depended on the dish stored, but usually the expectation was three days for leftovers. She stated she expected leftovers to be labeled, dated, and covered with the date to throw it away. The DM stated that it is all staff responsibility to ensure food is labeled, dated, or thrown out when expired or past the date. Interview on 02/22/24 at 2:34 PM the Administrator was informed of the findings in the kitchen. He stated the Dietary Manager is responsible for ensuring expired foods are thrown out and all foods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 8 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0812 are labeled and dated. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's document titled Food receiving and storage revised July 2014 indicated in part: Residents Affected - Many Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 9 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 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 2 residents (Resident #43) reviewed for infection control. Residents Affected - Some CNA A failed to wash hands or use hand sanitizer between glove changes during incontinent care while assisting Resident #43. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Record review of Resident #43's face sheet revealed admission date of 09/07/23 with diagnoses of hemiplegia of right side (one-sided paralysis), Type 2 Diabetes Mellitus (condition where pancreas does not produce enough insulin), cerebrovascular disease (blood flow to brain is affected), He was [AGE] years of age. Record review of Resident #43's MDS dated [DATE] indicated in part: BIMS 09 -moderately impaired. Urinary and Bowel continence = Always incontinent. Record review of Resident #43's care plan dated 09/08/2023 indicated in part: Focus: Resident at risk for frequent infections, pressure ulcers, venous stasis ulcers related to Diabetes Mellitus. Goals: Resident will remain stable. Interventions: Inspect skin for signs or symptoms of skin breakdown. During an observation on 02/21/24 at 02:10 PM CNA A performed incontinent care for Resident #43. CNA A put on gloves, failing to wash hands prior. CNA A pulled brief down in front, wiped front peri area with wet wipes, three times. Resident was assisted to turn to right side. CNA A wiped resident's buttocks until free of bowel movement. CNA Doffed(took off) gloves and donned(put on) clean gloves and placed brief under resident, failing to wash hands or use hand sanitizer when changing gloves. CNA A assisted resident to roll to back, brief was secured, resident was dressed, resident was positioned for comfort, CNA A doffed gloves. During an interview on 02/22/24 at 1:40 PM CNA A stated that during incontinent care, handwashing or using hand sanitizer was very important to prevent spread of infection. _CNA stated that she should wash hands before putting gloves on, stated she was nervous and forgot that step. During an interview on 2/22/24 at 2:25 PM the ADON stated that she has a lot of agency staff currently and it is difficult to ensure they are all following policy. The ADON stated that is not an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 10 of 11 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 - Some excuse, since handwashing and hand hygiene procedures are universal. The ADON stated that her expectations were that every staff member follow hand hygiene to prevent spread of infection. During an interview on 02/22/24 at 11:24 AM the DON stated that the steps for incontinent care were as follows: Introduction, hand washing, gather supplies, ensure resident is aware of what is going on, peri care- wiping from front to back, change gloves between soiled to clean, use hand sanitizer, change gloves for clean brief, help reposition resident to a comfortable position, gather trash, wash hands. During an interview on 02/08/24 at 02:52 PM the Administrator said the staff were expected to follow policy. The Administrator stated he was disappointed since the DON is constantly doing staff training. Record review of the facility's infection control policy titled Hand washing /hand hygiene revised April 2012 indicated in part: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Employees must wash their hands: Before and after direct contact with resident; before and after assisting resident with toileting; after contact with residents' mucous membranes and bodily fluids; after handling soiled linens, dressings, bedpans, catheters, and urinals, and after removing gloves. Hand hygiene is always the final step after removing and disposing PPE. The use of gloves does not replace handwashing/ hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 11 of 11