Health inspection·December 8, 2023

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for one of one infection preventionist reviewed. Residents Affected - Many The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. This deficient practice could place residents at risk of cross contamination and infection. Findings included: During an interview on 12/08/23 at 11:15 AM, the ADM stated the DON was the Infection Preventionist for the facility. During an interview on 12/08/23 at 2:55 PM, the ADM stated the previous IP had left the facility in August. She stated she was not aware if any other staff who had completed the IP training. The ADM presented a copy of the DON's completion of module 13 of the IP training and stated she did not have the certification of completion yet. During an interview on 12/08/23 at 4:19 PM, the ADM stated she had a screen shot of the IP training transcript and a screen shot of the certificate. She stated the DON did not work in the position of IP on a part time basis. Review of the DON's personnel file revealed she was hired on 10/25/23. Review of the screen shot of the DON's IP training transcript reflected the DON had completed the IP training 11/01/23. Review of the facility's undated policy titled Infection Preventionist Designation and Responsibilities reflected in part, Qualifications: 2. Be qualified by education, training, experience or certification; 3. Work at least part-time at the facility . Page 1 of 3 675948 675948 12/08/2023 Avir at Belton 810 E 13th Ave Belton, TX 76513

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza immunizations of 3 of 7 residents (Residents #1, Resident #2, and Resident #3) reviewed for immunizations. Residents Affected - Some The facility failed to ensure Resident #1, Resident #2, and Resident #3 received education on the influenza immunization. This failure could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes. Findings include: Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility 06/01/21 and readmitted [DATE]. Her diagnoses included atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of fats in the artery wall), dysphagia (difficulty in swallowing food or liquid), severe protein-calorie malnutrition, cauda equina syndrome (bundle of nerves below the end of the spinal cord known is damaged which can cause low back pain, pain that radiates down the leg, and loss of bowel or bladder control), hypertension (high blood pressure), and unspecified osteoarthritis (Inflammation of one or more joints). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Review of Resident #1's physician order dated 12/14/22 reflected, Resident may have flu vaccine annually per consent and CDC recommendations. Review of Resident #1's immunization record reflected she had been given the influenza vaccine on 10/31/23. Review of Resident #1's progress notes from 10/17/23 through 12/08/23 reflected no documentation of ifluenza vaccine education provided to the resident. Review of Resident #2's undated face sheet reflected a [AGE] year-old female admitted to the facility 06/10/20. Her diagnoses included anxiety, dysphagia (difficulty in swallowing food or liquid), contracture both hands (tightening of the muscles and tendons causing the joints to shorten and stiffen), cognitive communication deficit (difficulty with communication resulting from a brain injury), Alzheimer's disease, and hypertensive heart disease without heart failure (high blood pressure). Review of Resident #2's quarterly MDS assessment dated [DATE], reflected she was sometimes understood and sometimes understood others. The assessment reflected she had impaired short- and long-term memory impairment. Review of Resident #2's physician order dated 01/24/22 reflected, annual influenza vaccine if family agrees and no contraindications. Review of Resident #2's immunization record reflected she had been given the influenza vaccine on 675948 Page 2 of 3 675948 12/08/2023 Avir at Belton 810 E 13th Ave Belton, TX 76513

F 0883 10/31/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's progress notes from 10/17/23 through 12/08/23 reflected no documentation of ifluenza vaccine education provided to the resident. Residents Affected - Some Review of Resident #3's undated face sheet reflected a [AGE] year-old female admitted to the facility 03/29/17. Her diagnoses included unspecified dementia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (obstructed air flow from the lungs), repeated fall, cognitive communication disorder (difficulty with communication resulting from a brain injury), osteoporosis (bone strength weakens and is susceptible to fracture), and atrial fibrillation (irregular heartbeat). Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. Review of Resident #3's physician order dated 01/21/22 reflected, annual influenza vaccine if family agrees and no contraindications. Review of Resident #3's immunization record reflected she had been given the influenza vaccine on 10/31/23. Review of Resident #3's progress notes from 10/17/23 through 12/08/23 reflected no documentation of ifluenza vaccine education provided to the resident. During an interview on 12/8/23 at 4:10 PM, Resident #1 stated she had been provided with education about the flu vaccine but, Not this time but I wasn't going to object anyway. During an interview on 12/8/23 at 4:20 PM, the ADM stated the DON and ADON were responsible for administering and documenting immunizations including the education provided. She stated the consents for the immunizations were uploaded to the electronic medical record but the education was not included on the consent form. She stated usually the residents are provided with the VIS (vaccine information sheet) but she was unable to find any documentation of the VIS. The ADM stated both the DON and ADON were out of the building . Review of the facility's undated policy titled Vaccinations - Residents and Staff, reflected in part, Residents 3. Upon admission to the facility, permission must be obtained from the resident or representative to administer influenza vaccine annually (in the fall). The policy did not address providing or documenting education about the immunization. 675948 Page 3 of 3