Health inspection·January 30, 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 observation, interview, and record review, the facility failed to ensure the facility established and maintained 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 one (Resident #1) of two residents reviewed for infection control practices. Residents Affected - Few CNA C and CNA D failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 01/30/24, revealed the resident was a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infections, constipation, and benign prostatic hyperplasia (enlarged prostate). Review of Resident #1's MDS assessment, dated 01/17/24, revealed Resident #1 required extensive assistance with most ADLs and one person assist. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's care plan, dated 12/27/23, revealed the resident was care planned for bowel but not bladder incontinence. Observation of incontinence care for Resident #1 on 01/29/24 at 2:38 p.m. revealed CNA C and CNA D did not wash their hands or perform hand hygiene before the start of care. Both CNAs donned gloves. CNA C wiped Resident #1 from front to back making 5 strokes of clean with same soiled wipe. Resident #1's brief was soiled with urine and fecal matter. CNA C picked up the clean brief and placed it on the trash bag where the dirty wipes were kept. Her gloves were visibly soiled but she continued to clean the resident with it. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves while repositioning and putting back the resident clean sheets and pillows. She also walked out of the room without washing hands and returned without performing hand hygiene and assisted in putting Resident #1 clothes on. CNA C and CNA D doffed their gloves, picked up the trash and left the room without washing their hands or performing hand hygiene. In an interview on 01/29/24 at 2:54p.m. with CNA C she stated she had been employed at the facility Page 1 of 2 455916 455916 01/30/2024 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for about 1 month. She worked for the facility previously for 7 months. CNA C said she did not receive infection control training during her orientation. She stated cross contamination meant mixing clean with dirty. CNA C noted she should have washed hands and changed gloves at the appropriate times while providing care. She stated Resident #1 could get an infection for not using good infection control practice. Interview with CNA D on 01/30/24 at 1:42 p.m. revealed she had been employed at the facility for about 7 months. She stated she received infection control training from the facility 2 months ago. She stated cross contamination was transferring germs from one place to another. CNA D noted she should have changed her gloves and washed her hands after repositioning resident and changing her clean sheets. During an interview with the DON on 01/30/24 at 4:17 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the aides were expected to follow standard precautions to include appropriate hand washing and hand hygiene when providing incontinent care. The facility's infection control policy manual 2019 revealed, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1) Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.: a) When coming on duty: b) When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . c) Before and after assisting a resident with personal care . 455916 Page 2 of 2