Health inspection·June 27, 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 review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #2 and #3) reviewed for infection control. Residents Affected - Few 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident #2 2. CNA B failed to utilize proper hand hygiene during incontinence care for Resident # 3. These failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a history of Dementia (impaired ability to remember), generalized anxiety disorder, and hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE], Section C Cognitive patterns revealed Resident #2 had a BIMs score of 08 which indicated the resident had moderate cognitive impairment. MDS Section Hbladder and bowel revealed the resident was always incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan dated 4/23/24 revealed the resident had urinary incontinence and required the use of briefs. During an observation on 6/26/2024 at 9:41 PM, revealed CNA A donned (put on) clean gloves after washing her hands with soap and water. CNA A cleaned Resident #2's peri area with wet wipes, doffed (took off) her gloves, and donned new gloves. No hand hygiene was utilized between the glove change. CNA A removed Resident #2's soiled brief, cleaned the resident with wet wipes, and doffed her gloves. No hand hygiene was performed prior to donning new gloves. CNA A secured Resident #2's clean brief, adjusted Resident #2 in bed, and doffed her gloves. CNA A did not perform hand hygiene prior to exiting Resident #2's room. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male, admitted to the Page 1 of 4 675346 675346 06/27/2024 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE]. Resident #3 had a history of COPD (chronic obstructive pulmonary disorder, obstructive airflow), hypertension (high blood pressure), atrial fibrillation (heart arrythmia), and cognitive communication deficit. Record review of Resident #3's MDS dated [DATE] Section C- Cognitive patterns revealed Resident #3 had a BIMs score of 10, which indicated Resident #3 had moderate cognitive impairment. MDS Section Hbladder and bowel revealed resident was always incontinent of bladder and always incontinent of bowel. Record review of Resident #3's care plan dated 3/26/24 revealed resident had urinary incontinence and required the use of briefs. During an observation on 6/26/2024 at 10:00 PM, revealed CNA B donned gloves to provide incontinence care to Resident #3. No hand hygiene was performed prior to donning gloves. CNA B unfastened Resident #3's brief, cleaned the resident with wet wipes, and assisted the resident to turning to Resident #3's left side. CNA B cleaned Resident #3's bowel movement, discarded the dirty wet wipes and brief. While still wearing the same gloves, CNA B walked to Resident #3's closet, opened the doors, removed a clean brief from the closet and walked back to complete incontinence care. CNA B placed a clean brief under the resident, turned Resident #3 on his back and fastened the brief. CNA B utilized Resident #3's remote to lower the head of the bed, and adjusted Resident #3 in bed to his comfort. CNA B doffed his dirty gloves and discarded them in the trash can. CNA B removed the dirty trash from Resident #3's room and exited the room. No hand hygiene was utilized by CNA B before care, during care, or after incontinence care. During an interview with CNA B on 6/26/24 at 10:16 PM, he stated he had been at the facility for the past 2 months and a CNA for three years. He stated he did not know who the infection preventionist was and he did not remember the last training on infection control. He stated he had been trained on infection control during his CNA Program and at a different facility. He stated the negative outcomes of not utilizing infection control was spreading diseases to residents. He stated the best practice for infection control was handwashing. He stated he thought he changed his gloves at least one time during the incontinence care. He stated he should have changed his gloves and performed had hygiene before touching anything else in the room. During an interview with CNA A on 6/26/24 at 10:35 PM, she stated she did not know who the infection preventionist was. She stated she had training on infection prevention and the last in-service was November of 2023. She stated the negative outcomes of not utilizing infection control is spreading infection and passing it on to other people. CNA A stated she was nervous and forgot to use hand sanitizer between glove changes. During an interview with the ADM on 6/27/24 at 11:14AM, he stated the ADON was responsible for training on infection control and the ADON was the infection preventionist. He stated that walking rounds were conducted to monitor for infection control, and hand hygiene. He stated they also monitored for increased infection rate and the amount of UTI's (urinary tract infections) to monitor infection control. He stated his expectation of staff was to follow the regulation of infection prevention and wash hands after every resident contact. He stated the negative outcomes of not utilizing infection control was sepsis (a serious condition in which the body responds improperly to an infection), infection, UTI's, ill residents and cross contamination. He stated he was not aware of the staff not utilizing proper infection prevention technique. 675346 Page 2 of 4 675346 06/27/2024 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 6/27/24 at 11:21AM, she stated the ADON was the infection preventionist. She stated the educator and charge nurses help with training. She stated audits are conducted on peri-care, resident charts, and monthly antibiotic monitoring with QAPI to monitor infection rates, and infection control. She stated they conduct hand hygiene audits as well to monitor for infection prevention. She stated her expectation of staff is for them to wash their hands prior to entering a resident room, before touching a resident, when removing gloves, any incontinence care and to utilize proper PPE (personal protective equipment). She stated the negative outcome of not utilizing proper infection control is sepsis, passing infection to other residents or passing infections to staff. She stated she was not aware of staff not utilizing proper infection control or prevention technique. During an interview with the ADON on 6/27/24 at 11:35 AM. She stated she was the infection preventionist. She stated staff training is conducted between the ADON, DON and the educator. She stated they have a checklist that is followed, and they will bring staff in to perform hand hygiene and provide feedback as needed. She stated for night shift, she will come in around 5pm and monitor handwashing for evening staff as well. She stated her expectation of staff was for them to wash their hands between residents, and utilize frequent handwashing as needed . She stated the negative outcome of not utilizing infection control and prevention was risk of UTI's, spreading infection and viruses. She stated she was not aware of staff not utilizing proper infection control practices. During an interview with LVN A on 6/27/24 at 11:49AM, she stated the ADON was the infection preventionist. She stated she was the educator and does training as an ongoing daily practice. She stated her expectation of staff was for them to follow policy, procedure, and hand hygiene practices. She stated the risk of not utilizing proper infection control and prevention was risk of infection, increasing infection rates and cross contamination. She stated she was not aware of staff not utilizing proper infection control and prevention technique. Record review of facility policy titled Employee training on Infection Control, last revised on January 2022, revealed: The facility shall provide staff with appropriate information and instruction about infection control through various means including initial orientation and ongoing training programs . 1. All staff and personnel will complete orientation and training on preventing the transmission of healthcare associated infections. 2. The infection preventionist and administrator will identify those disciplines or individuals who need task- or job- specific infection control training beyond that provided by initial orientation or policies and procedures. Record review of facility policy titled Handwashing/Hand Hygiene, last revised on 1/20/2023 revealed: This facility considers hand hygiene the primary needs to prevent the spread of infection . 675346 Page 3 of 4 675346 06/27/2024 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0880 Level of Harm - Minimal harm or potential for actual harm 1. All personnel should value their hand washing campaign and procedures to help prevent the spread of infection to other personnel resident and visitors. 5. Hand hygiene must be performed prior to donning and after doffing gloves. Residents Affected - Few 675346 Page 4 of 4