Health inspection·November 15, 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 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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices. Residents Affected - Few CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 11/15/23, revealed a 76- year- old female admitted to the facility on [DATE] with diagnoses including senile degeneration of brain and morbid obesity. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was frequently incontinent of bladder and always of bowel. Review of Resident #1's Care Plan undated revealed she had bowel and bladder incontinence. Observation of incontinence care for Resident #1 on 11/14/23 at 2:55 p.m. revealed CNA A did not wash her hands prior to donning gloves in the hallway. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A again, did not wash her hands before exiting Resident #1's room. In an interview on 11/14/23 at 3:05 p.m. with CNA A, she revealed she should have washed her hands before starting care and changed her gloves during care. CNA A also revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she had infection control training about one year ago. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 11/15/23 at 2:22p.m., she revealed she was aware of some of the Page 1 of 2 455570 455570 11/15/2023 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0880 concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Hand hygiene policy undated reflected, Residents Affected - Few 1) You may use alcohol-based hand cleaner or soap/water for the following: a) When coming on duty . b) Before or after assisting a resident with personal care (e.g., oral care, bathing) 2) You must soap/water for the following (Alcohol-based cleaner is not recommended) a) When hands are visibly b) After personal use of the toilet (hand washing with soap and water) c) Before and after assisting a resident with toileting (hand washing with soap and water) 455570 Page 2 of 2