Health inspection·August 20, 2025

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, including hand hygiene, 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 #2) of fifteen residents reviewed for infection control practices, in that: The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior and after performing Resident #2's wound care. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections. Findings include:Record review of Resident #2's face sheet dated 08/19/25 reflected a [AGE] year-old-female with an original admission date of 05/06/2012. Diagnoses included Alzheimer's disease (progressive brain disorder that slowly damages memory, thinking, and learning skills), dementia (loss of thinking, remembering, and reasoning skills), cerebral infarction (occurs when the blood vessel in the brain is blocked, leading to a lack of blood supply and oxygen to the brain), chronic atrial fibrillation (long-standing and persistent uncoordinated activation of the atria leading to irregular heartbeats) and hypertension (high blood pressure). During an observation on 08/19/2025 at 9:00 AM, the WCN washed her hands for approximately 9 seconds prior to providing wound care on Resident #2. During an observation on 08/19/2025 at 9:21 AM, the WCN washed her hands for approximately 18 seconds after completing wound care on Resident #2. Record review of Resident #2's physician orders dated 06/20/25 reflected:Cleanse re-opened stage four (severe type of pressure injury, extending deeply into muscle, tendons, and even bone) to coccyx (tailbone) with normal saline, pat dry with gauze, apply collagen sheet (aides in enhancing the body's natural healing process that promotes new tissue growth) to wound bed, cover with calcium alginate (highly absorbent dressing made from alginate that promotes moisture balance and keep wounds clean and supports the healing process) and cover with silicone super absorbent dressing (absorbent dressing that aides in wound healing) daily and as needed. In an interview on 08/19/2025 9:25 AM, the WCN stated hand washing should be at least 20 seconds or greater. The WCN stated she sang Happy Birthday twice in her head and thought she washed her hands long enough. She stated she was nervous. The WCN stated washing hands for the appropriate amount of time was important to stop the spread of infection and to prevent cross contamination. The WCN stated Resident #2's wound could get infected if exposed to bacteria. In an interview on 08/20/2025 at 9:13 AM, the DON stated staff should perform hand hygiene for 20 seconds minimum to ensure to get all the bacteria off the hands, around the wrist, the cuticles, and under the nails. The DON stated Resident #2 could be at risk for infection if the wound came in contact with germs. In an interview on 08/20/2025 at 9:16 AM, the Staff Development Nurse stated when washing hands, the lathering should be done for a minimum of 20 seconds to create friction. The Staff Development Nurse stated staff are taught to sing Happy Birthday twice or count to 20 seconds during the lathering process to prevent cross contamination. The Staff Development Nurse stated the WCN was checked of last Residents Affected - Few Page 1 of 2 455923 455923 08/20/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few month on handwashing and did well with no concerns. The Staff Development Nurse stated the WCN was probably just nervous. Record review of the facility's Handwashing/Hand Hygiene policy dated August 2019 reflected:Policy StatementThis 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. ProcedureWashing Hands2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Record review of the facility's Hand Washing Procedure Form reflected: WHAT IS THE RIGHT WAY TO WASH YOUR HANDS?Rub your hands together to make a lather and scrub them well; be sure to scrub the backs of your hands, between fingers & under your nails.Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song twice from beginning to end. 455923 Page 2 of 2