Health inspection·December 1, 2025

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 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 1 Resident of 3 (Resident#1), reviewed for infection control. The facility failed to ensure that CNA A performed hand hygiene before providing peri care. The facility failed to ensure that CNA A provided perineal care according to professional standards of practice when she cleaned a female resident (Resident#1) perineal area from back to front, rather than from front to back which is consistent with professional standards. This failure could cause residents the risk of urinary tract infections and compromise their health and safety. Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 07/08/25, reflected the resident was a [AGE] year-old female, who admitted on [DATE], had a BIMs score of 15 indicating she was cognitively intact. The resident had diagnoses which included arthritis, hypotension (low blood pressure), urinary tract infections, anxiety, and asthma.Record review of Resident #1's Comprehensive Care Plan, revised 08/11/2025 reflected the resident had bowel incontinence. Facility interventions included: Check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, take resident to toilet PRN as requested.10/13/25 at 11:38am Incontinent care observation on Resident #1 by CNA A revealed Resident#1 had a bowel movement and her brief was wet. CNA A entered Resident #1's room and did not perform hand hygiene. CNA A donned clean gloves, unfastened Resident #1's brief, cleaned the resident from back to front. Removed dirty gloves, donned cleaned gloves, touched trash can and moved it closer then touched clean brief, applied brief on the resident and fastened the brief. CNA A then removed gloves and washed her hands.10/13/25 at 11:56 AM interview with CNA A revealed she knew that she was supposed to perform hand hygiene before and after peri care. She stated she forgot to perform hand hygiene before peri care. She stated the professional standard was to clean the resident from front to back, and there was no reason she cleaned the resident from back to front. She stated that the risk to the resident when cleaned from back to front was urinary tract infection. She stated that she had been in-serviced on infection control, hand hygiene and peri care. An interview on 10/13/25 at 1:41 PM with DON revealed that his expectation was that the staff should perform hand hygiene before and after care, or when the gloves were contaminated by touching surfaces such as trash cans. He also stated that when providing peri care the staff should clean the residents from front to back. He stated that the risk to a female resident being cleaned from back to front was the urinary tract infections. The risk of not performing hand hygiene was infection control. He stated that the staff had been in-serviced and had completed skills checkoffs on infection control and peri care. The facility policy titled Perineal Care Revised February 2018 reflected: The purpose of this procedure is to provide cleanliness and comfort to the resident to prevent infection and skin irritation and observe the residents' skin condition.Steps in the Residents Affected - Few Page 1 of 2 675840 675840 12/01/2025 Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procedure1. Beginning stepsa. Wash hands. Wear gloves and follow Standard Precaution if contact with blood or body fluid is likely.b. Gather needed supplies.If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag.Female:1. Follow below:Cleanse the perineal are with wipes going from front to back/clean to dirty.Separate the labia (clean to dirty)Use a new wipe with each stroke.Wipe one side, wipe the other side down the center and then once from hip bone to hip bone. The facility policy titled Infection Control and Prevention Program Revised October 2018 reflected:An infection prevention and control program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Policies and proceduresa. Policies and procedures are utilized as the standard of the infection prevention and control programb. Policies and procedures reflect the current prevention and control standards of practicec. The infection prevention and control committee, medical director, director of nursing services and other key clinical and administrative staff review the infection control policies at least annually. The review will include:1. Updating or supplementing policies and procedures as needed.2. Assessment of staff compliance with existing policies and regulations andAny trends or significant problems since the previous review 675840 Page 2 of 2