Health inspection·February 21, 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 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. Page 1 of 2 675035 675035 02/21/2024 Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354

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 . 675035 Page 2 of 2