Inspection·April 23, 2024

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) viewed for infection control. Residents Affected - Few The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these items. During an interview on 4/23/24 at 9:02 am the Treatment Nurse said after he picked up the napkin off the bedside table and oxygen tubing out of the floor his gloves would have been contaminated. The Treatment Nurse said he only touched the dirty dressing with the contaminated gloves in place. The Treatment Nurse said it would be important to change gloves and perform hand hygiene after picking items up from a bedside table or the floor was because the gloves that were worn when picking these items up were contaminated. During an interview on 4/24/24 at 1:17 p.m. the DON said while providing care to a resident if a staff member picked up something off the bedside table or the floor, she expected them to perform hand hygiene prior to continuing care. The DON said if the care required gloves, she would expect the staff to change gloves and perform hand hygiene. The DON said the importance of proper hand hygiene and changing glove was to prevent cross contamination. Record review of the facility's Handwashing/Hand Hygiene policy revised 12/22/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Use can alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .g. Before handling clean or soiled (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675666 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarcliff Health Center of Greenville 4400 Walnut St Greenville, TX 75401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)