Health inspection·June 29, 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 maintain an infection control program designed to prevent the development and transmission of infection for one of one resident (Resident #1) observed for infection control. Residents Affected - Few The facility failed to ensure CNA A and CNA B performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk for infection. Findings include: A record review of Resident #1's Comprehensive MDS assessment, dated 04/28/2023, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with Diabetes Mellitus, Major Depressive Disorder, and Anemia. Resident #1 had a BIMS of 08 which indicated Resident #1's cognition was moderately impaired. Resident#1 required extensive assistance of two-person physical assistance with toilet use and personal hygiene. Observation on 06/29/23 at 09:36 AM revealed CNA A provided incontinent care to Resident #1. CNA A had gloves on, brief opened, and was wiping the bedside table down with clean with wipes. CNA A proceeded to clean Resident #1's genital area with wipes. CNA A wiped front to back once and threw each wipe away. CNA A removed his gloves and used hand sanitizer. CNA A put on new gloves. Resident #1 helped CNA A to roll to the side. CNA A tucked the soiled brief into itself and pulled it out. CNA A tucked the old sheet under the resident. CNA A removed his gloves and used hand sanitizer. CNA A put on new gloves. CNA A used wipes to clean stool off Resident #1's buttocks. With the same gloves on, CNA A tucked a clean brief under Resident #1 and rolled the resident to get the brief fully under. CNA A then clasped the clean brief while wearing the same gloves. CNA A touched the air conditioner unit with while wearing the same gloves. CNA A then removed his gloves and performed hand hygiene in the restroom. Observation on 06/29/2023 at 09:45 AM revealed CNA B to remove three pillowcases from Resident #1's pillows . One pillowcase appeared to have a yellow and brownish stain on it, which appeared to be same color as Resident #1's stool. CNA B placed the dirty pillowcases into a trash bag. CNA B removed his gloves. CNA B did not perform hand hygiene and touched Resident #1's drawer and removed mouth wash and took the lid off. CNA B then poured mouth wash into a cup. Resident #1 took the cup and used mouth wash. CNA B performed hand hygiene after Resident #1 was done with mouth wash. In an interview on 06/29/23 at 09:45 AM with CNA A, he stated he was to wash his hands when Page 1 of 2 675503 675503 06/29/2023 Beacon Hill 3515 S Park Ave Denison, TX 75020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few entering the room. CNA A stated to perform hand hygiene after several wipes while cleaning the resident or when gloves were soiled. CNA A stated he thought he did do hand hygiene after cleaning Resident #1's stool. CNA stated he thinks he was rushing. CNA A stated he was supposed to change gloves and complete hand hygiene to prevent cross contamination and has been trained to do so by facility. In an interview on 06/29/23 at 10:14 AM with CNA B he stated he was to wash his hands before putting on gloves. CNA B stated to do hand hygiene before providing another service to the resident. CNA B stated he should have washed his hands after handling the soiled pillowcase and the facility trained him to do that. CNA B stated he did not think to do hand hygiene at that time. CNA B stated he was supposed to change gloves and complete hand hygiene to prevent cross contamination. In an interview on 06/29/23 at 02:301 PM with the DON, she stated that staff were to complete hand hygiene before and after care as well as anytime they changed their gloves. The DON also stated in between care the CNA was to complete hand hygiene after cleaning the resident during incontinent care and after touching any soiled linens. The DON stated the staff were to complete hand hygiene during care to prevent infection . Record review of the facility policy reviewed February 2022, titled Perineal Care Protocol reflected, Cleaning the perineal area . helps prevent .infection . If needed clean soiled areas first by wiping off fecal material with wipes. Wash hands and apply gloves . Record review of the facility policy reviewed March 2013, titled Bedmaking (occupied) reflected, Wash hands .take soiled linen off .Dispose of properly in linen hamper to avoid contamination 675503 Page 2 of 2