Avir At Arden Wood
Inspection Findings
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
gloves, and masks before entering the room. If the signage is not on the door, she would contact the nurse or the infection control preventionist. During an interview with LVN E on 12/30/2025 at 10:09am, she stated
the last in-service for PPE was a few weeks ago. It would depend on what the resident has going on to determine if PPE is needed, but the EBP signage will confirm what is necessary before entering the room.
If there is no signage, she would confirm with the infection control preventionist, due to the risk of infection spreading. During an interview with CNA Y on 12/30/2025 at 10:27am, stated before entering the room, the signage will be on the door to clarify if the staff use sanitizer before and after visiting with the resident, who is not on contact. If there are three bins by the door, staff is to use all equipment before entering the room, such as mask, gloves, and gown which indicates the resident is on contact. If the signage is missing, she would speak with the nurse to confirm what is needed before entering the room. The last in-service for EBP was a month ago. The risk of the signage missing is not protecting the resident and herself from infection.
During an interview with ADMN on 12/30/2025 at 10:52am, the ADMN said the facility staff discuss anyone
in isolation to know who is on EBP and what equipment is needed prior to entering the room. The facility's procedure for EBP is to decide if the equipment is hanging on the door, use sanitizer or wash hands and if there is a bin outside the room door, use everything for isolated residents to protect the residents and staff from possible risk of infection. During an interview with RN C on 12/30/2025 at 11:42am, RN C, who is the facilities infection preventionist, stated the EBP signs have been missing and she does replace them at least once a week. There was an in-service in the month of December on EBP and contact for all staff. She has been replacing EBP signs at least once a week, because they have been disappearing. The residents with missing signage, are not on contact and she clarified the residents are on EBP due to their diagnosis.
Before staff or any visitor enter a resident room for isolation there is equipment in a bin outside of the door for gloves, mask, and gown to be put on prior to entering the room. For residents with EBP, if the resident is not touched, it is safe to go in the room. If the sign is missing, the staff/visitor should check with the charge nurse, ADON, or infection preventionist. The risk of no signage on the door is a chance of infection for the residents or staff because the PPE is used to protect the residents from staff. During an interview with CNA J on 12/30/2025 at 1:30pm, CNA J stated EBP is known by the isolation cart outside of the room for PPE usage before entering the room. If the resident is not in isolation, there will be PPE on the door, which is necessary if they need to touch the resident or have any type of physical contact. If the sign is missing, she would check with the charge nurse, ADON, and Infection Preventionist on how to proceed before entering
the room. The last in-service for EBP and isolation was a few weeks ago. The risk of the signage not being
on the door is infection, bacteria, and transmitting. On 12/30/2025 at 1:57pm it was observed that all rooms needed for EBP had signage on the door. Record review of an in-service dated 10/25/2025 for EBP for contact vs. EBP. It read as. contact requires the box isolation cart (strict) EBP has the hanging equipment
on the door. EBP is precautionary. Signage on door for EBP and contact isolation precautions. The in-service was completed by RN C and signed by all staff. Record review of the facility's policy for Enhanced Barrier Precautions, dated for March 2024. EBPs are indicated (when contact precautions do not otherwise apply) for resident with wound and/or indwelling medical device regardless of MDRO colonization.11. Signs are posted in the door or wall outside of the resident room indicating the type of precautions and PPE required.
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AVIR AT ARDEN WOOD in HOUSTON, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HOUSTON, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVIR AT ARDEN WOOD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.