Health inspection·November 29, 2023

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 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 4 staff (CNA C) and 1 of 4 residents (Resident #1) reviewed for infection control. Residents Affected - Few CNA C did not wash or sanitize her hands when changing gloves while performing incontinent care to Resident #1. These failures could place residents at risk of exposure to communicable diseases and infections. Findings Included: Record review of a Face Sheet for Resident #1 dated 11/29/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type (a mental illness that can affect thoughts, mood and behavior), spastic diplegic cerebral palsy (muscle stiffness mainly in the legs) and generalized anxiety disorder (a condition of excessive worry about everyday issues and situations). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 15. She was totally dependent with ADLs with 2-person physical assist. She was always incontinent of bowel/bladder. Record review of a Care plan for Resident #1 dated 6/14/2023 indicated she had ADL functional status and required assistance with ADLs x2 female staff members at all times and was incontinent of bowel and bladder and required extensive-total assist x2 staff with pericare. During an observation of incontinent care on 11/27/2023 at 10:00 AM, CNA B and CNA C washed their hands and applied gloves. CNA C opened and pulled down Resident #1's brief and provided pericare using wipes. CNA C removed her gloves and placed them in the trash and applied clean gloves without washing or sanitizing her hands. CNA B turned Resident #1 to her right side and CNA C cleaned her buttocks using wipes and removed the soiled brief and her gloves and placed them in the trash. CNA C sanitized her hands and applied gloves. Both CNA B and CNA C placed a clean brief underneath Resident #1's buttocks and secured it. Both CNA B and CNA C removed their gloves and placed them in the trash and washed their hands. During an interview on 11/27/2023 at 10:29 AM, CNA C said she was a mobile support worker and had been assigned to work in the facility multiple times. She said she was instructed to wash or sanitize Page 1 of 2 455565 455565 11/29/2023 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0880 Level of Harm - Minimal harm or potential for actual harm her hands after 3 glove changes with any care provided to the residents. She said the care provided to Resident #1, she thought she had sanitized her hands between glove changes. She said the Regional Nurse conducted trainings with staff weekly on pericare and handwashing and she had been trained and observed. She said residents could be at risk for infection if they did not wash or sanitize their hands between glove changes. Residents Affected - Few Record review of a perineal care return demonstration form dated 11/10/2023 for CNA C by Regional Nurse indicated CNA C completed the demonstration correctly. During an interview on 11/29/2023 at 9:10 AM, the Regional Nurse said she was responsible for conducting checkoffs with all staff on pericare and handwashing/hygiene. She said CNA C's last check off with her was in October 2023. She said CNA C was a mobile support worker who was assigned shifts at the facility but did not work at the facility on a full time basis. She said staff were always being trained on hand hygiene. She said staff should be sanitizing their hands between glove changes. She said the DON was ultimately responsible for conducting check offs with staff, but she had been doing them when she visited the facility. She said residents could be at risk of infection control if staff did not sanitize or wash hand between glove changes. During an interview on 11/29/2023 at 10:55 AM, the Administrator said the DON, ADON and delegates were responsible for conducting skill check offs with staff on hand washing and hygiene. He said staff should be sanitizing or washing their hands between glove changes. He said the Regional Nurse had been conducting check offs with the staff when she was at the facility. He said going forward they would continue to in-service staff with return demonstration and perform random audits. He said residents could be at risk for infections. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of 1/20/2023 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Hand hygiene must be performed prior to donning and after doffing gloves . 455565 Page 2 of 2