Health inspection·November 6, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **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 6 of 8 Residents (Residents #1, #2, #5, #6, #7, and #8) reviewed for infection control. Residents Affected - Some 1. The facility failed to place signage on the door indicating Resident #7's need for droplet isolation precautions due to positive COVID-19 status. 2. The facility failed to ensure CNA A and NA B wore a gown, gloves, and goggles or a face shield upon entering Resident #1, #2, #5 and #6's room who was on contact and droplet isolation for COVID-19. 3. The facility failed to ensure NA B used appropriate hand hygiene when exiting a room under contact and droplet precautions and before entering a resident room who had not tested positive for COVID-19 and when touching her own N95 facemask, face and hair. 4. The facility had an outbreak beginning on 10/14/23, which encompassed 27 staff and 57 residents. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 11/4/23 at 4:19 p.m. The IJ template was provided to the facility on [DATE] at 4:19 p.m. While the IJ was removed on 11/6/23, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with infection control standards. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness. Findings included: 1. Record review of a untitled facility document revealed 57 residents had tested positive for COVID-19 from 10/14/2023-to current (10/27/2023). Record review of Resident #7's face sheet dated 10/27/2023 revealed an admission date of 1/12/2023 with a readmission date of 9/26/2023 with diagnoses which included: COVID-19 (10/26/2023), type 2 diabetes mellitus, and morbid obesity due to excess calories. Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMs score of 15 which Page 1 of 9 675931 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 indicated the resident was cognitively intact. Level of Harm - Immediate jeopardy to resident health or safety Record review of a facility document titled Root Cause Analysis, dated 10/26/23, revealed the following: Residents Affected - Some One staff members [sic] tested positive for COVID Via [through] antigen testing (10/14/2023). RCA Events: Two staff members tested positive for Covid on 10/16/2023 during the 48 hour follow-up testing. two staff member [sic] tested positive for Covid on 10/17/23023. Three staff member [sic] tested positive for Covid on 10/18/1023. 1 staff member tested positive for Covid on 10/19/2023. (12 employees.) 3 employee [sic] tested positive for Covid 10/20/2023. 2 employee [sic] tested positive for Covid 10/22/23. Total 22 employees 77 retruned =15 employees with Covid. 10/24/2023. 10/25/2023-11 employees 10/26/2023-13 employees, 1 Prn Nurse, 1 can [sic] & 1 dietary cook. One resident tested positive on 10/14/2023. Two residents tested positive on 10/17/2023. 12 residents tested positive on 10/18/2023. 4 resident [sic] tested positive on 10/19/2023. 11 residents tested positive on 10/20/2023. Total of 49 residents with Covid on 10/24/2023. 10/25/2023 46 residents. During an observation/interview on 10/27/2023 at 12:07 p.m. Resident #7 was observed from the doorway to be in bed. His room did not have any signs indicating he was under any isolation precautions and there was no PPE outside of his door. Resident #7 stated he was feeling bad because he had COVID-19. He stated he just found out yesterday (10/26/2023). He stated he had a sore throat, headache, and body aches. During an observation on 10/27/2023 at 12:29 p.m. CNA A and NA B entered Resident #7's room briefly and interacted with the resident. They did not put on gown, gloves, or eye protection before 675931 Page 2 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 entering the room. Level of Harm - Immediate jeopardy to resident health or safety During an observation/interview on 10/27/2023 at 12:31 p.m., NA B stated she did not think Resident #7 had COVID-19 but she was not sure. She stated she was not really sure which residents had COVID-19 and which did not. NA B stated she thought the residents who had COVID-19 had signs on their doors for what to wear in the room. During the interview, NA B walked to Resident #7's room and looked at the door. She stated she did not think Resident #7 had COVID-19 because he did not have a sign on the door. NA B stated she was new to the facility. She stated it was her 3rd day working and was still on orientation. She stated CNA A was providing her training. Residents Affected - Some During an interview on 10/27/2023 at 12:39 p.m., CNA A stated she was training NA B. She stated she was showing her how to take care of the residents. When asked if she had trained NA B on PPE use and COVID-19 isolation precautions, CNA A stated, she knows to put it on. CNA A stated residents were identified as positive for COVID-19 by the sign on their door. She stated Resident #7 did not have a sign on his door indicating he was under isolation precautions. CNA A stated Resident #7 was positive for COVID-19, and she thinks Resident #7 tested positive yesterday morning (10/26/23). CNA A stated she did not wear gloves, gown, or face protection in Resident #7's room because she forgot. During an interview on 10/27/2023 at 2:05 p.m., LVN C stated Resident #7 tested positive for COVID-19 on 10/26/2023. She stated she immediately notified housekeeping staff and the CNAs on the hallway he was positive. LVN C stated she did not put any signage on Resident #7's door for isolation precautions. She stated she was working with another staff member, testing residents for COVID. She stated she should have put signage on the door indicating isolation precautions, but it just slipped through the cracks. LVN C stated appropriate isolation precautions for someone who tested positive for COVID-19 would be gloves, gown, N95 mask and a face shield. 2. Record review of Resident #1's face sheet dated 10/27/2023 revealed an admission date of 2/23/2023 with a readmission date of 5/19/2023 with diagnoses which included: unspecified dementia with agitation, type 2 diabetes mellitus and COVID-19 (10/22/2023). Record review of a physician order for Resident #1 dated 10/23/2023 revealed: Isolation precautions: contact/droplet for COVID-19. Record review of Resident #1's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included Ensure resident/family aware of isolation precautions related to current infection. Record review of Resident #2's face sheet dated 10/27/2023 revealed an admission date of 10/28/2022 with diagnoses which included: sequelae of cerebral infarction (care following a stroke), generalized anxiety disorder and COVID-19 (10/22/2023). Record review of a physician order for Resident #2 dated 10/23/2023 revealed: Isolation precautions: contact/droplet for COVID-19. Record review of Resident #2's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included: Ensure resident/family aware of isolation precautions related to current infection. Record review of Resident #5's face sheet dated 10/27/2023 revealed an admission date of 10/21/2022 675931 Page 3 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 Level of Harm - Immediate jeopardy to resident health or safety with readmission date of 3/30/2023 with diagnoses which included: schizophrenia (a mental health disorder), vitamin D deficiency, and COVID-19 (10/22/2023). Record review of Resident #5's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included Ensure resident/family aware of isolation precautions related to current infection. Residents Affected - Some Record review of Resident #6's face sheet dated 10/27/2023 revealed an admission date of 12/28/2023 with diagnoses which included: generalized anxiety disorder, Down Syndrome (intellectual disability), and constipation. Record review of Resident #8's face sheet dated 10/27/2023 revealed an admission date of 10/17/2022 with diagnoses which included: Alzheimer's disease, major depressive disorder and constipation. During an observation on 10/27/2023 at 12:15 p.m., revealed CNA A and NA B entered Resident #1 and Resident #2's room with signs on the door indicating they were under contact and droplet isolation precautions without donning gloves, gown, or eye protection to deliver meal trays and provide meal set up assistance. PPE was observed in a portable plastic cart immediately outside this room. During an observation on 10/27/2023 at 12:18 p.m., revealed CNA A and NA B entered Resident #5 and Resident #6's room with signs on the door indicating the residents were under contact and droplet isolation precautions without donning gloves, gown, or eye protection to deliver meal trays and provide meal set up assistance. CNA A was observed assisting Resident #5 with positioning and touched both the resident, wheelchair, and bedside table. Resident #5 was observed handing CNA a used napkin. During the interaction, CNA A bent down to Resident #5 and with their faces only inches apart she exchanged a conversation with the resident. CNA A was wearing a N95 mask but Resident #5 was not wearing any mask. PPE was observed in a portable plastic cart immediately outside this room. During an observation on 10/27/2023 at 12:26 p.m. revealed CNA A entered Resident 8's room who was COVID-19 negative to provide feeding assistance. During an interview on 10/27/2023 at 12:31 p.m., NA B stated she was trained to wear a gown, gloves and a face shield when entering resident rooms with COVID. She stated she had not worn a gown, gloves or a face shield when entering resident rooms who were positive for COVID because she did not know where the protection was located. She stated she did not ask for assistance or ask anyone where they were kept the PPE. NA B stated she had been working with CNA A as an orientee and CNA A had not told her to wear PPE in COVID-19 positive rooms. During an interview on 10/27/2023 at 12:39 p.m. CNA A stated she had not worn the appropriate PPE for droplet precautions in rooms where resident had tested positive for COVID-19 because she forgot. She stated she had been trained to wear a gown, gloves, and eye protection in rooms with droplet precautions for COVID, but she forgot. CNA A stated it was important to follow contact and droplet precautions, so she did not spread the germs. 3. During an observation on 10/27/2023 at 12:21 p.m. revealed NA B exited Resident #5 and Resident #6's room with signs on the door indicating the residents were under contact and droplet isolation precautions. As NA B exited the room she did not complete any hand hygiene and she reached up and grabbed the front of her facemask and adjusted the mask and then walked into Resident #3 and Resident #4's room who did not have isolation precaution signs without washing or sanitizing her hands. 675931 Page 4 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 10/27/2023 at 12:22 p.m. CNA A and NA B stated the Residents #5 and #6 had tested negative for COVID-19 and were not under any isolation precautions. During an observation on 10/27/2023 at 12:24 p.m. revealed NA B was observed accepted a used meal tray from an unknown resident with unknown COVID-19 status who had been walking down the hallway. NA B placed the used meal tray in the tray cart and then touched her face and hair and then adjusted her facemask all without using hand hygiene. During an observation on 10/27/2023 at 12:27 p.m. revealed NA B entered a resident room (unknown name) who was not on isolation precautions and again touched and adjusted the front of her N95 facemask while talking to the resident. During an interview on 10/27/2023 at 12:31 p.m. NA B stated she was touching her N95 facemask for she could pull the mask away from her face so she could breathe. NA B stated she had been trained to wear PPE and use hand hygiene when exiting a resident room and when touching her face. She stated she did not have access to hand sanitizer except for a container she kept in her pocket. NA B stated she knew it was important to wear appropriate PPE and to not touch her face or facemask or pull the mask away from her face to breathe because it would spread germs and cause infection. During an interview on 10/27/2023 at 12:58 p.m. the Infection Preventionist stated she has been out of the facility because she had tested positive for COVID-19, and this was her first day back. She stated without reviewing records it was not clear to her which residents was positive and who was negative for COVID-19. During an interview on 10/27/2023 at 2:28 p.m., the Infection Preventionist/ADON/MDS Coordinator stated the facility did not currently have a DON. She also stated the other ADON and Administrator were out because they were sick. She stated the facility was having a large outbreak and were unable to cohort residents by COVID-19 status. She stated there were COVID-19 positive and COVID-19 negative residents on some hallways. She stated a sign should include precautions for contact and droplet precautions. She stated donning and doffing instructions should also be posted on every COVID-19 positive resident door as a visual cue to ensure staff know how to do it right. The Infection Preventionist/ADON/MDS Coordinator stated staff should wear a gown, gloves, N95 mask and either a face shield or goggles, even if they only went into the room for a short time. She stated hand hygiene should include washing of the hands with soap/water when coming out of a COVID-19 positive room. She stated the CDC alcohol-based hand sanitizer was sufficient for COVID-19. The Infection Preventionist/ADON/MDS Coordinator stated the facility was not able to put hand sanitizer out in the hallway or resident rooms due to the type of resident population the facility house which included behaviors. She stated hand sanitizer was in the bins (plastic containers) outside the resident rooms. She stated if staff were not caring for resident who were COVID-19 positive, then they could use the hand sanitizer they kept in their pockets. She stated staff should not touch or adjust their N95 facemasks. She stated she had provided an in-service training recently about isolation precautions. She stated it was important to prevent contamination and they follow CDC guidelines. Record review of an in-service training dated 10/14/2023 titled Infection Control/COVID Precautions revealed: airborne precautions, contact precautions, standard precautions, Infection Control Policy, COVID symptoms, COVID-19 guidelines and PPE guidelines had been reviewed with staff. A review of the sign in sheet for the training revealed CNA A and NA B had not signed the sheet as having attended. 675931 Page 5 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 10/27/2023 at 3:05 p.m., the Infection Preventionist/ADON/MDS Coordinator stated she was unable to find CNA A's signature on the in-service training on 10/14/23. She stated NA B was not an employee of the facility when the in-service was given. Record review of a facility policy titled Responding to Coronavirus (COVID-19) in Nursing Homes (undated) revealed: Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. HCP (Health Care Providers) should use all recommended COVID-19 PPE for care of all residents on affected units (or facility-wide if cases are widespread). Record review of a facility policy titled Hand Hygiene dated 2012 revealed: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. 1. Handwashing: When hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids .perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water 2. Waterless Handwashing products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under handwashing above. Record review of a facility policy titled Infection Control Policy (undated) revealed: This facility will follow most current CDC guidelines. Record review of a facility policy titled Contact Precautions dated 2012 revealed: 2. Gloves and Hand Hygiene: A. Hand Hygiene should be completed prior to donning gloves B. Gloves should be worn when entering the room and while providing care for the resident. D. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. 3. Gowns: A. A gown should be donned prior to entering the room . Record review of a facility policy titled Droplet Precautions: dated 2012 revealed: Droplet Precautions shall be used in addition to standard precautions .2. A mask should be worn when entering the resident's room . Record review of a facility policy titled Standard Isolation Precautions dated 2001 revealed: 3. Masks, Eye Protection, Face Shields A. Wear a mask and eye protection or a face shield to protect mucous membranes. 4. During a follow-up interview on 11/4/23 at 1:50 p.m., the ADON stated after the outbreak on 10/14/23, the facility educated their staff on infection control and transmission-based precautions. The ADON stated some staff members may not have been educated because the staff member may have been off schedule due to COVID-19. Record review of the facility's education dated from 10/14/23 - 10/26/23, revealed a total of 54 out of 63 total staff members were educated on COVID-19 and infection prevention standards. The Administrator, the ADON, and the co-owner were notified of an IJ on 11/4/23 at 4:19 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 11/5/23 at 9:36 a.m. and included the following: 1. Staff inservice on the Infection Control Program with emphasis on prevention and precautions. This packet includes education on upper respiratory virus prevention of transmission with skills check 675931 Page 6 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 off. See attached. This began on 11/1 [2023] and concludes on 11/5 [2023]. All working staff by 11/5 [2023] will be inserviced prior to starting their shift on 11/6 [2023]. Packet contains the following information: Level of Harm - Immediate jeopardy to resident health or safety a. Donning [putting on] and Removal of PPE. Return Demonstration and observation of proper use and sequencing.Skills Check off. Residents Affected - Some b. Handwashing/Glove Use: Return Demonstration and observation. Skills Ck off. c. Proper signage for door and facility for upper respiratory virus prevention and protection. d. Droplet precautions, airborne precautions, standard precautions, and contact precautions education. Transmission and Spread of infection education. The Administrator and Infection Control Preventionist will insure all staff are inserviced by 11/5 [2023]. Regional Nurse Consult will verify on 11/10/23. At am [a.m., referring to morning] report all new employees inservice on Infection Control Policy will be reviewed. This has begun 11/4 [2023]. Administrator will report compliance to qapi and any concerns immediately addressed.This begins 11/4/2023. 2. Observation and Auditing of Compliance a. 1/4ly at payroll all staff will be inserviced on Infection Control Program with return demonstration of proper use of PPE. b. Starting on 11/5 [2023] the facility will utilize the following audit tools for the infection prevention, Monitoring Compliance with Infection Prevention Policies by Observation, Environmental Checklist for Monitoring Environmental Cleaning, Compliance Rounds(Contact Precautions), and Compliance(Droplet Precautions). See attached. i. Monitoring Compliance with Infection Prevention Policy and Observation. This tool will be utilized 3x per week selecting 5 employees on various shifts by designated personnel from the Administrator and Infection Control Preventionist. Any deficient practice will be corrected with Return Demonstration and noted. This is to begin 11/5 [2023]. ii. Compliance Rounds(Contact Precautions) and (Droplet Precautions). This tool will be utilized 3x per week on various shifts monitoring the resident room who has precautions. This is to begin on 11/5 [2023]. Any deficient practice will be immediately corrected and findings brought to am report. iii. Environmental Checklist. This tool will be utilized 3x per week on various shifts by designated personnel from the administrator and Infection Control Preventionist. Administrator will report compliance to qapi and any concerns immediately addressed. This begins 11/4/2023. Regional Nurse consult will verify weekly beginning 11/10/23. 675931 Page 7 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 The surveyor verification of the Plan of Removal on 11/5/23 to 11/6/23 was as follows: Level of Harm - Immediate jeopardy to resident health or safety From 11/5/23 at 2:58 p.m. to 11/6/23 1:45 p.m., 45 of the 55 target staff members across all shifts (CNA, NA, LVN, Dietary Staff, Housekeeping Staff, Activities Director, Maintenance, Transporter, Medical Records, and Administrator) were interviewed. All 45 of the 55 staff members interviewed were able to verbalize they received education on the infection control policy, putting on of PPE, removing PPE, hand washing, proper signage, and transmission-based precautions. Residents Affected - Some During a joint interview on 11/6/23 at 1:45 p.m., the Administrator and the Infection Preventionist stated the new employees will be required to do training on the infection control policy. The Administrator stated the Regional Nurse will arrive on 11/10/23 to verify the facility's audits and infection control compliance. The Administrator and Infection Preventionist were interviewed and stated all staff will be trained on the infection control policy and PPE use on a quarterly basis. The facility will target the date the staff must come in to pick up their checks. The Administrator and Infection Preventionist stated they are currently using audits to monitor compliance with Infection Control, transmission-based precautions, and environmental cleanliness. The Administrator stated she will report compliance to the facility's QAPI meeting. During an interview on 11/6/23 at 2:12 p.m., the Regional Nurse Consult stated she will be performing direct observations to ensure compliance with infection control, putting on PPE, removing PPE, posting of signage, and transmission-based precautions. Record review of facility educational in-services, dated 11/5/23, revealed the facility educated 55 employees across all shifts on infection control policy. Record review of a facility document titled, Monitoring Compliance with Infection Prevention Policies by Observation, dated 2012, revealed the facility was currently using an audit for monitoring compliance with hand hygiene, PPE usage, standard precautions, and transmission-based precautions. 5 employees have been observed for compliance. Record review of a facility document titled, compliance Rounds: Droplet Precautions, dated 2012, revealed the facility was currently using an audit for monitoring compliance with droplet precautions and ensuring appropriate PPE and signage was outside a resident's room. Record review of a facility document titled, compliance Rounds: Contact Precautions, dated 2012, revealed the facility was currently using an audit for monitoring compliance with droplet precautions and ensuring appropriate PPE and signage was outside a resident's room. Record review of a facility document titled, Environmental Checklist for Monitoring Terminal Cleaning, dated 2012, revealed the facility was currently using an audit to monitor compliance of resident room cleaning. Record review of the facility's agenda revealed the Administrator will report compliance to the QAPI and any concerns immediately addressed. This would begin 11/4/23. Record review of an adhoc QAPI meeting agenda revealed an adhoc meeting occurred on 11/4/23 to discuss the IJ and implementation of audits. Sign-in sheet of this meeting revealed 8 attendees, including the medical director, administrator, ADON, and other QAPI members. 675931 Page 8 of 9 675931 11/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0880 Level of Harm - Immediate jeopardy to resident health or safety On 11/6/23 at 4:56 p.m., the Administrator, the ADON, and the co-owner were notified the IJ was removed. However, the facility remained out of compliance at a level of actual harm with a scope identified as pattern due to the facility's need to monitor the implementation and effectiveness of its POR. Residents Affected - Some 675931 Page 9 of 9