Health inspection·August 22, 2023

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 observation, interview, and record review, the facility failed to establish and 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. Residents Affected - Some The facility failed to ensure that facility staff performed hand hygiene appropriately during the delivery of food trays to nine of forty-two residents in the three hundred hall of the facility. This failure could place the residents at an increased risk of exposure to viral infections, secondary infections, communicable diseases, and feelings of isolation related to poor hygiene. Findings Included: Observation on 8/22/23 at 11:43 AM, revealed CNA A obtained a food tray from the mobile food cart and delivered it to room [ROOM NUMBER]. CNA A exited room [ROOM NUMBER], did not practice hand hygiene, obtained another tray from the cart, and delivered it to room [ROOM NUMBER]. Upon exiting, CNA A did not practice hand hygiene and obtained another tray from the cart. CNA A delivered the tray to 312. Upon exiting, CNA A obtained another tray and delivered a second tray to 312. CNA A exited the room, returned to the cart, obtained a tray, and delivered it to 319. CNA A left room [ROOM NUMBER] with no hand hygiene practiced after exiting. CNA A obtained an additional tray from the cart and delivered it to room [ROOM NUMBER]. No hand hygiene was practiced upon exiting. CNA A obtained another tray from the cart and delivered a second tray to room [ROOM NUMBER]. In an interview on 8/22/23 at 11:51 AM, CNA B stated that hand hygiene needs to be practiced between every tray or every other tray. In an interview on 8/22/23 at 1:22 PM, ADON A stated that the policy for hand hygiene is included when hand hygiene is to be performed. ADON A Statedstated that staff should use hand sanitizer between patients, between trays, the policy is more detailed than just those two instances. ADON A indicated that hand hygiene should be practiced after everything, and hands should especially be washed if visibly soiled. ADON A revealed that hand hygiene competency is every month and spot checks are completed. ADON A stated a negative outcome of not practicing proper hand hygiene would be cross contamination to the residents. In an interview on 8/22/23 at 1:43 PM with CNA C indicated hand hygiene is practiced when leaving the room and hands need to be washed after every third room. CNA C stated that policy used is infection control. CNA C Statedstated that a negative outcome is germs and residents contracting anything else. Page 1 of 2 675498 675498 08/22/2023 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 8/22/23 at 3:13PM with the DON revealed that in services on hand hygiene are practiced as often as necessary. If anything comes up, we they do it proactively. The DON indicated that not practicing hand hygiene between trays is not practicing policy. The DON Indicatedindicated a negative outcome is not following infection control or for the betterment of the patients. In an interview on 8/22/23 at 3:17 PM, the ADM indicated that handwashing in services is are at least monthly and that it has been done quite a bit. The ADM Statedstated that observation of staff by surveyor was not policy that has been taught of the facility. The ADM stated that a negative outcome could be it can spread infection to the residents. In an interview on 8/22/23 at 4:55PM, CNA A stated hand sanitizer should have been used while passing lunch trays. CNA A Indicatedindicated she just got busy and forgot. CNA A stated that it is possible that hands should be washed after using hand sanitizer 3 times. In an interview on 8/22/23 at 4:55PM, CNA A stated hand sanitizer should have been used while passing lunch trays. CNA A Indicatedindicated she just got busy and forgot. CNA A stated that it is possible that hands should be washed after using hand sanitizer 3 times. Record review of Infection Prevention and Control Policies and Procedures, revised on May 15, 2023, revealed under the heading of Procedures, section 1: Hand hygiene/hand washing is done before: Line Beating or preparing, distributing, handling, serving food. After-Line J - Contact with environmental surfaces in the immediate vicinity of patients/residents. Record review of Infection Prevention and Control Policies and Procedures, revised on May 15, 2023, revealed under the heading of Procedures, section 1: Hand hygiene/hand washing is done before: Line Beating or preparing, distributing, handling, serving food. After-Line J - Contact with environmental surfaces in the immediate vicinity of patients/residents.In an interview on 8/22/23 at 3:17 PM, the ADM indicated that handwashing in services is are at least monthly and that it has been done quite a bit. The ADM Statedstated that observation of staff by surveyor was not policy that has been taught of the facility. The ADM stated that a negative outcome could be it can spread infection to the residents. 675498 Page 2 of 2