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
observations, interviews, and record reviews, the facility failed to establish and
Residents Affected - Few
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 for
1(Resident #1) of 2 residents reviewed for infection control practice.
CNA (Certified Nurse Assistant) A failed to perform hand hygiene and change her 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 02/21/24, revealed the resident was a 61- year- old female
admitted to the facility on [DATE] with diagnoses of personal history of Covid-19, urinary tract infection, viral
disease, candidiasis (fungal infection), streptococcal infection (bacterial infection), and constipation.
Review of Resident #1's MDS assessment, dated 12/27/23, revealed Resident #1 has a brief interview for
mental status (BIMS) of 13 indicating cognitively intact. Resident required extensive assistance with most
ADL s and one person assist. Resident #1 was always incontinent of bowel and bladder.
Review of Resident #1's care plan dated 03/28/24, revealed the resident was care planned for urinary
incontinence but not for bladder incontinence.
Observation of incontinence care for Resident #1 on 02/20/2 at 11:02a.m. revealed CNA A did not wash her
hands but put on gloves before commencing care. She wiped the resident from front to back. Resident #1
brief was soiled with urine and fecal matter. CNA A gloves were visibly soiled but she continued to use it to
clean the resident. CNA A did not wash 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. CNA A
removed her gloves, picked up the trash and walked out of the room without washing hands or performing
hand hygiene.
Interview with CNA A on 02/20/24 at 11:12 a.m. revealed she had been employed at the facility for about 1
year and received infection control training 2 weeks ago. She stated cross contamination was mixing clean
with dirty. CNA A stated she should have washed hands before starting and after providing care. She added
that Resident #1 could get infection for not using good hand hygiene.
(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:
675035
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
675035
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Burkburnett
406 E Seventh St
Burkburnett, TX 76354
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
During an interview with the DON on 02/21/24 at 11:23a.m she acknowledged she was aware of some of
the concerns raised about infection control. She said she expected her staffs to gather supplies, wash
hands and donned gloves before and after providing care. The DON stated she was responsible for
infection control in the facility. She explained the facility conducts infection control training with return
demonstration quarterly. She noted the ADON does surprise checks on staffs to ensure they are following
good infection control practice.
Review of the facility handwashing/hand hygiene policy revised 01/20/23 reflected, This facility considers
hand hygiene the primary means to prevent the spread of infections.
Policy interpretation and implementation:
1)
All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents, and visitors.
2)
Residents, family members and/or visitors will be encouraged to practice hand hygiene throughout the
facility.
3)
Wash hands with soap and water, when hands are visibly soiled and after contact with resident with
infectious diagnosis .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675035
If continuation sheet
Page 2 of 2
