F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, record review and facility policy review, the facility failed to ensure staff
performed hand hygiene during wound care for 1 (Resident #55)of 1 sampled resident reviewed for
pressure ulcer/injury.
Residents Affected - Few
Findings include:
A facility policy titled, Handwashing/Hand Hygiene, revised 10/2023, specified, Indications for Hand
Hygiene. 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site
on the same resident. The policy further specified, 4. Single-use disposable gloves should be used: a.
before aseptic procedures.
An admission Record revealed the facility admitted Resident #55 on 04/14/2023. According to the
admission Record, the resident had a medical history that included a diagnosis of pressure ulcer of the
sacral region, stage 4.
Resident #55's Order Summary Report, revealed an order dated 08/09/2024, for staff to cleanse Resident
#55's coccyx wound with wound cleanser, pat it dry, pack the wound with collagen powder, cover with
calcium alginate and a foam dressing every day.
During an observation of wound care on 08/21/2024 from 10:11 AM to 10:25 AM, Licensed Vocational
Nurse (LVN) #1 provided wound care to Resident #55. At 10:19 AM, LVN #1 removed the resident's soiled
dressing and packing. LVN #1 disposed of the dressings and gloves, washed her hands, and applied clean
gloves. At 10:21 AM, LVN #1 cleaned and dried the resident's wound according to the physician's order,
and then immediately packed the wound with collagen powder and calcium alginate and applied the foam
dressing. LVN #1 did not perform hand hygiene and apply clean gloves before she applied medication and
a clean dressing to the resident's wound, after cleaning the soiled wound. At 10:23 AM, LVN #1 washed her
hands, applied clean gloves, washed a second surface wound on the resident's right buttock, patted it dry,
and applied zinc cream. LVN #1 did not perform hand hygiene or change gloves between cleaning the
wound and applying the medicated cream.
During an interview on 08/21/2024 at 11:29 AM, LVN #1 stated cleaning the wound was considered a dirty
procedure and the application of the medication and dressing was considered a clean procedure. LVN
#1stated she should have cleaned her hands after she cleaned each wound and before she applied the
medications on both of the resident's wounds and the clean dressing on the resident's coccyx wound.
During an interview on 08/21/2024 at 12:59 PM, the Infection Preventionist (IP) stated the nurse should
have cleaned her hands after she cleaned the wound, because it was considered a dirty
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555244
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555244
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Anberry Nursing and Rehabilitation Center
1685 Shaffer Rd
Atwater, CA 95301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
procedure. The IP stated the nurse should have cleaned her hands and applied clean gloves before she
applied medication and clean gloves because it was considered a clean procedure. The IP stated the way
the nurse completed wound care meant she wore dirty gloves during the clean procedure, and the potential
risk was transmission an infection.
During an interview on 08/21/2024 at 1:44 PM, the Director of Nursing (DON) stated she expected the
nurse to perform wound care to wash her hands, apply clean gloves, remove the soiled dressing, wash her
hands, and apply clean gloves and then clean the wound. The DON stated next, the nurse should have
washed her hands and applied clean gloves before she applied medication and a clean dressing. The DON
stated for the second wound, the nurse should have cleaned her hands, applied clean gloves and after
cleaning the area and then applied the medicated cream. The DON stated cleaning a wound was
considered a dirty procedure, and the application of medication and dressings, was considered a clean
procedure. The DON stated potential risk was the nurse's contaminated hands could cause an infection in
the wound.
During an interview on 08/21/2024 at 1:48 PM, the Administrator stated she expected the nurse to clean
her hands before she applied medications and dressings. She stated for the second wound she expected
the nurse to wash her hands before she applied the medicated cream. The Administrator stated hand
hygiene prevented the spread of infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555244
If continuation sheet
Page 2 of 2
