Health inspection·December 12, 2025

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, and record review, the facility failed to 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 and infections for 1 of 3 staff (Treatment Nurse) and 1 of 1 resident (Resident #1) reviewed for infection control. The facility failed to ensure the Treatment Nurse performed appropriate glove changes and hand hygiene between glove changes while performing wound care on Resident #1 on 12/12/25. This failure could place residents at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings included: During an observation on 12/12/25 at 10:07 a.m., the Treatment Nurse did not perform hand hygiene, applied clean gloves, entered Resident #1's room, cleansed the bedside table, laid down a barrier (a protective pad to keep wound care supplies clean), set her supplies on top of the barrier, and removed her gloves. The Treatment Nurse did not perform hand hygiene and applied clean gloves. The Treatment Nurse removed the dirty dressing from Resident #1's sacral area (triangular-shaped bone at the base of the spine that supports the upper body's weight while sitting), removed her gloves, did not perform hand hygiene, and applied clean gloves. The Treatment Nurse cleansed the wound to Resident #1's sacral area, did not change gloves and did not perform hand hygiene. The Treatment Nurse applied collagen powder (a powder that forms a protective gel and creates a moist environment to speed up wound healing for chronic wounds) to Resident #1's wound on her sacral area and covered with a bordered dressing (an absorptive dressing consisting of three layers). The Treatment Nurse did not change gloves or perform hand hygiene. The Treatment Nurse removed the sock from Resident #1's right foot and observed the wound/discolored area to Resident #1's right heel. The Treatment Nurse applied betadine to Resident #1's right heel. The Treatment Nurse removed her gloves, did not perform hand hygiene, gathered her trash, exited the room, disposed of her trash, got a clean blanket off the linen cart and handed it to a CNA (name unknown), and then performed hand hygiene. During an interview on 12/12/25 at 10:32 a.m., the Treatment Nurse said she had received training on wound care from the DON. The Treatment Nurse said she usually performed hand hygiene prior to entering a resident room and upon exiting a resident room. The Treatment Nurse said glove changes should be performed after removing a dirty dressing and when going from one wound to another. The Treatment Nurse said she did not routinely perform hand hygiene between glove changes. The Treatment Nurse said the importance of proper hand hygiene and glove changes was infection control. During an interview on 12/12/25 at 12:20 p.m., the DON said she expected staff to perform hand hygiene before providing care, during care, after care, and any time gloves were changed. The DON said gloves should be changed when going from a dirty area to a clean area, after every step in providing care such as removing dressing, cleansing a wound, and then putting the wound treatment and dressing on a wound, and when going from one wound to another wound. The DON said the importance of appropriate glove changes and hand hygiene was to prevent infections and cross contamination. Record review of the facility's Wound Care policy, Residents Affected - Few Page 1 of 2 675320 675320 12/12/2025 Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few last revised October 2010, indicated, The purpose of this procedure is to provide guidelines for the care of wounds and promote healing .Steps in the Procedure.2. Wash and dry hand thoroughly.4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly (hand sanitizer can be used). 6. Put on gloves.16. Discard disposable items into the designated container. Discard all soiled laundry, linens, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly .23. Wash and dry your hands thoroughly. Record review of the facility's Handwashing/Hand Hygiene policy, last revised October 2023, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene 1. Hand Hygiene is indicated: a. immediately before touching a resident.c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident.f/ before moving from work on a soiled body site to a clean body site on the same residents; and g. immediately after glove removal. 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 675320 Page 2 of 2