Health inspection·March 8, 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 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 for one of three residents (Resident #2) reviewed for infection control practices. Residents Affected - Few CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #2. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #2's face sheet, dated 03/06/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included constipation, retention of urine, age-related debility (weak state) and Alzheimer's disease (brain disorder). Record review of Resident #2's Minimum Data Set (MDS) quarterly Assessment, dated 12/08/22, reflected Resident #2 required substantial/maximal assistance with most activities of daily living (ADLs) and always incontinent of bowel and bladder. Observation on 03/06/24 at 10:49 a.m. of incontinence care for Resident #2 revealed CNA A and CNA B did not wash their hands before the start of care. Both donned gloves and removed Resident #2 old brief. CNA A wiped from front to back. Resident #2's brief was soiled with urine and fecal matter. CNA A did not change gloves but continued to clean Resident #2. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #2's clean brief and placing it underneath the resident and fastening the brief. CNA B assisted CNA A to provide care. CNA B repositioned the resident and touched the resident's perineal area. She changed gloves and washed hands before helping to fasten Resident #2 clean brief. CNA A and CNA B removed their gloves, picked up the trash and walked out of Resident #2's room, without washing their hands. In an interview on 03/06/24 at 11:12 a.m., CNA A said she had been employed at the facility for about 2-3 weeks and did not receive infection control training during orientation. CNA A stated cross contamination was mixing clean with dirty. CNA A stated she should have washed her hands before she retrieved Resident #2's clean brief and fastened it. She stated Resident #2 could get an infection for not following good infection control practice. Page 1 of 3 675767 675767 03/08/2024 Regency House 3745 Summer Crest Dr San Angelo, TX 76901

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During interview on 03/06/22 at 11:16 a.m. with CNA B, she said cross contamination was going from clean to dirty. She stated not changing gloves before she fastened Resident #1's clean brief. CNA B stated she had been employed about 6 weeks and did not receive infection control training during orientation. In an interview on 01/30/23 at 12:21 p.m., the DON stated she was aware of some of the concerns raised about infection control practices. She explained ADON D was responsible for infection control in the facility. She trained and monitored staff with return demonstration. The DON stated aides were expected to follow standard precaution which included washing hands and changing gloves while providing care. Record review of the facility's policy and procedure, revised February 2018, reflected the following: Handwashing /Hand Hygiene Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and h. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap ( antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents. 675767 Page 2 of 3 675767 03/08/2024 Regency House 3745 Summer Crest Dr San Angelo, TX 76901

F 0880 . Level of Harm - Minimal harm or potential for actual harm f. Before donning sterile gloves. g. Before handling clean or soiled dressings, gauze pads, etc. Residents Affected - Few ii. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves 675767 Page 3 of 3