Health inspection·August 9, 2024

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 observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Residents #1 and #2) of 5 residents reviewed for infection control, in that: Residents Affected - Some PTA B failed to follow droplet precautions for Resident #1 by not donning an N95 mask respirator or eye protection prior to entering the room to perform therapy services. CNA C failed to follow droplet precautions for Resident #2 by not donning eye protection prior to entering the room to provide care services. These failures could affect residents and place them at risk for cross contamination and infections. Findings included: 1. Review of Resident #1's face sheet, dated 08/09/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #1's admission MDS Assessment, dated 07/29/24, reflected she had a BIMS score of 15 indicating no cognitive impairment. Further review revealed she had active diagnoses of depression and a hip fracture. Review of Resident #1's undated Continuity of Care Document reflected a Problem of 2019-nCoV acute respiratory disease with an effective date of 08/02/24. Further review revealed under Results and COVID-19 Test was COVID-19 Test Viral Antigen with a date of 08/01/24 and the word Positive. Review of Resident #1's physician order report for 07/09/24 to 08/09/24 reflected the following: Isolation with droplet precautions for covid-19; Resident to remain in private room, all services to be provided to resident in resident's private room. [DX: 2019-nCoV acute respiratory disease] with a start dated of 08/02/24 and end date of 08/11/24. Review of Resident #1's care plan, dated 08/05/24, reflected the following: Problem: Problem Start Date: 08/02/2024, Category: Nursing, Resident requires isolation control precautions as evidence by droplet isolation precautions related to ____ .Approach: follow infection control policy . Observation on 08/09/24 at 9:15 AM, of Resident #1's room revealed there was a three-drawer-bin on Page 1 of 4 676127 676127 08/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the outside of her room next to her closed door. Inside of the bin was gowns, gloves, masks (both N95 and surgical), and bio-hazard trash bags. There was no eye protection in the drawers. There was a sign posted on the door with the following information written on it: a stop sign with the word stop in it on the top left and right of the page; writing that said DROPLET PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .[a picture with a bottle of ABHR and a drop of it's contents on top of a hand being stretched out towards it] .Make sure their eyes, nose and mouth are fully covered before room entry .[two pictures side by side, one with a person wearing a face shield and one with a person wearing goggles with the word 'or' between them] .Remove face protection before room exit. Resident #1's door was closed each time it was observed. Observation on 08/09/24 at 12:15 PM revealed PTA B entered Resident #1's room with a surgical mask, gown, and gloves on. PTA B did not put on eye protection such as a face shield or goggles or an N95 mask on. There was a box of N95 masks on top of the three-drawer bin outside of Resident #1's room where PTA B retrieved the gown and gloves. There was also a set of face shields in one of the drawers as well. Observation on 08/09/24 at 12:20 PM of Resident #1's room revealed PTA B opened the door to get CNA D's attention. PTA B was observed still wearing a surgical mask, a gown, and gloves. PTA B requested CNA D help him provide incontinent care to Resident #1. CNA D donned a gown, gloves, face shield, and N95 mask before entering Resident #1's room. Interview on 08/09/24 at 12:34 PM, PTA B revealed he was aware Resident #1 had COVID and was positive. PTA B said he wore all PPE including a gown, mask, and gloves into Resident #1's room. PTA B said he saw two boxes of masks on top of the three-drawer bin, one of surgical masks and one of N95 masks so he thought it was optional which one he needed to wear inside the room. PTA B said he did not wear eye protection because he did not think he had to wear that as well even though he saw a face shield was available in one of the drawers for him to wear. PTA B said he was providing therapy services to Resident #1 while he was in her room. Interview on 08/09/24 at 12:37 PM, CNA D revealed she went into Resident #1's room to assist PTA B with providing incontinent care to her. CNA D said when she went into the room, she saw PTA B wearing a surgical mask, gloves, and a gown. CNA D said PTA B was not wearing an N95 mask or any eye protection. 2. Review of Resident #2's face sheet, dated 08/09/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #2's admission MDS assessment, dated 08/01/24, reflected he had a BIMS score of 03, indicating severe cognitive impairment. Further review revealed he had active diagnoses of vascular dementia and a stroke. Review of Resident #2's undated Continuity of Care Document reflected a Problem of 2019-nCoV acute respiratory disease with an effective date of 08/04/24. Further review revealed under Results and COVID-19 Test was COVID-19 Test Viral Antigen with a date of 08/04/24 and the word Positive. Review of Resident #2's care plan, dated 08/04/24, reflected the following: Problem; Problem Start Date: 08/04/2024, Category: Nursing, Resident requires isolation control precautions as evidenced by droplet precautions related to COVID DX 8/4 .Approach: follow infection control policy . 676127 Page 2 of 4 676127 08/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's physician order report for 07/09/24 to 08/09/24 reflected the following: Isolation with droplet precautions for Covid 19; Resident to remain in room, all services to be provided to resident in resident's private room. [DX: 2019-nCoV acute respiratory disease] with a start dated of 08/05/24 and end date of 08/14/24. Observation on 08/09/24 at 9:16 AM of Resident #2's room revealed there was a three-drawer-bin on the outside of his room next to his closed door. Inside of the bin was gowns, gloves, masks (both N95 and surgical), and bio-hazard trash bags. There was no eye protection in the drawers. There was a sign posted on the door with the following information written on it: a stop sign with the word stop in it on the top left and right of the page; writing that said DROPLET PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .[a picture with a bottle of ABHR and a drop of it's contents on top of a hand being stretched out towards it] .Make sure their eyes, nose and mouth are fully covered before room entry .[two pictures side by side, one with a person wearing a face shield and one with a person wearing goggles with the word 'or' between them] .Remove face protection before room exit. Resident #2's door was closed each time it was observed. Observation on 08/09/24 at 9:30 AM, CNA C entered Resident #2's room r wearing an N95 mask, gown, and gloves. CNA C was observed wearing prescription glasses but no other eye protection such as a face shield or goggles. CNA C entered the room with a trash bag and left the door open to walk into Resident #2's bathroom to replace the trash bag. CNA C was observed to have walked up to Resident #2's bed and provided care, then walked back to the door and closed it. CNA C was still only wearing a N95 mask, gown, and gloves with her prescription glasses. Interview on 08/09/24 at 11:15 AM, CNA C revealed she knew Resident #2 was positive for COVID-19. CNA C said she had to dress up in PPE before entering his room with a blue gown, gloves, and mask. CNA C said she did not put a face shield on to enter Resident #2's room because the IP told her she didn't have to since she wore glasses which would protect her eyes. Interview on 08/09/24 at 1:28 PM, the IP revealed she made rounds during the day to ensure staff were donning and doffing their PPE correctly before and after entering a COVID positive resident's room. The IP said staff were expected to put on the following items when entering a COVID positive resident's room: a gown, a mask, a face shield or eye wear, and gloves. The IP specified that the mask should be a N95 mask. The IP said all PPE supplies were available to all staff throughout the day as when she made rounds in the facility she added supplies to the three-drawer bins located outside of each resident's room. The IP said all staff knew what PPE to put on before entering a COVID positive resident's room because they had been in-serviced so much on exactly what to do. The IP said she had not told one specific person that they could wear glasses instead of a face shield into a COVID positive resident's room. The IP said any COVID positive resident was on droplet precautions. The IP said that the risk of staff not donning the correct PPE was that they could get infected themselves or infect someone else since COVID was based on droplets it was easily transferrable . Review of the facility's undated policy, titled COVID-19 Refresher reflected the following: Facility to follow local health department and CDC guidelines .PPE for COVID + or COVID suspected- N95, gown, gloves, face shield .You should utilize N95s for Covid positive rooms . Interview on 08/09/24 at 11:00 AM, the Administrator revealed the refresher policy was what facility followed along with CDC guidelines for everything related to COVID. Review of website https://www.cdc.gov/covid/hcp/infection-control/index.html, accessed on 08/09/24, 676127 Page 3 of 4 676127 08/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 Level of Harm - Minimal harm or potential for actual harm revealed the following: .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Residents Affected - Some 676127 Page 4 of 4