Health inspection·June 21, 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 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 3 residents (Resident #5) reviewed for infection control in that: Residents Affected - Few CNA A and CNA B failed to wash or sanitize their hands when changing gloves while providing incontinent care to Resident #5. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet dated 6/21/2023 for Resident #5 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of displaced intertrochanteric fracture of right femur (broken hip and thigh bone), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and end stage renal disease (kidney failure). Record review of a care plan for Resident #5 dated 4/12/2023 indicated a goal to provide maximum support as evidence by resident will be safe, clean and in good appearance daily. Record review of a Significant Change MDS assessment dated [DATE] for Resident #5 indicated he had moderate impairment in thinking with a BIMS score of 10. He required total dependence with transfers and extensive assistance with personal hygiene. He was frequently incontinent of bladder and always incontinent of bowel. During an observation on 6/21/2023 at 9:27 AM, CNA A and CNA B were in Resident #5's room to provide incontinent care. Both CNA A and CNA B had gloves on both hands. They assisted Resident #5 from his wheelchair to his bed using a mechanical lift. Incontinent care was provided to Resident #5 by CNA A and CNA B. CNA A pulled Resident #5's pants down to his ankles and opened his brief and cleaned his genital area with a wipe and placed it in the trash. CNA B assisted to roll Resident #5 to his right side. CNA A removed a wipe from the plastic bag and wiped Resident #5's rectal area using multiple wipes to remove feces. CNA A removed her gloves and placed them in the trash along with the brief and applied clean gloves without washing or sanitizing her hands. CNA A placed a clean brief underneath Resident #5's buttocks and he was repositioned on his back. Both CNA A and CNA B secured the brief and pulled his pants back up. CNA A and CNA B both removed their gloves and placed them in the trash and placed clean gloves on without washing or sanitizing their hands. Resident #5 was transferred back to his wheelchair using a mechanical lift. Both CNA A and CNA B washed their hands in Page 1 of 2 455673 455673 06/21/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0880 Resident #5's restroom before they exited the room. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/21/2023 at 9:46 AM, CNA B said she had been employed at the facility for 7 years. She said she should have washed her hands before entering the room and she did not wash or sanitize her hands between glove changes. She said she had received training on incontinent care and hand washing. She said a resident could get an infection if they did not wash or sanitize their hands between glove changes. Residents Affected - Few During an interview on 6/21/2023 at 9:48 AM, CNA A said she had been employed at the facility for 4 months. She said she should have washed her hands before entering the room and between glove changes. She said she had received training on incontinent care and infection control. She said a resident could get an infection if they did not wash or sanitize their hands between glove changes. During an interview on 6/21/2023 at 1:56 PM, the IP said she had been employed at the facility since November 2022. She said she was responsible for providing staff education and conducting skill check offs with the nurses and aides. She said when performing incontinent care, staff should keep sanitizer with them or wash their hands every time gloves were changed. She said staff should be washing or sanitizing their hands between glove changes. She said she conducted skills check off with both CNA A and CNA B in January 2023 that included infection control with hand hygiene. She said a resident could get an infection or it be carried to another resident when staff do not wash or sanitize their hands. During an interview on 6/21/2023 at 2:48 PM, the DON said she had been employed at the facility since August 2022. She said everyone knew to wash their hands between glove changes. She said going forward she would do more hands-on training with staff on hand washing/hygiene and incontinent care. She said residents were at risk for infection control. Record review of a CNA performance and skills evaluation checklist dated 1/21/2023 for CNA A indicated she had skills check off on infection control by the DON and IP. Record review of a CNA performance and skills evaluation checklist dated 1/25/2023 for CNA B indicated she had skills check off on infection control by the DON and IP. Record review of a one-on-one staff education dated 6/21/2023 by the IP indicated training on handwashing and infection control was provided to CNA A and CNA B. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .The facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based rub containing at least 62% alcohol; or, alternative, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. After removing gloves . 455673 Page 2 of 2