Health inspection·April 1, 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Residents Affected - Few CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 03/29/24. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 04/01/24, revealed an 84- year- old female admitted to the facility on 06/06//22 with diagnoses including Covid-19, overactive bladder, gastronomy (feeding tube) and dementia. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required total assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 02/15/22 revealed he had bowel and bladder incontinence related to over-active bladder. Observation of incontinence care for Resident #1 on 03/29/24 at 9:50 a.m. revealed CNA A used antiseptic and donned gloves (after retrieving the gloves her pocket) before commencing care. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine. CNA A used the same soiled gloves to apply skin protector to Resident #1. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A washed hands before leaving Resident #1's room. In an interview on 03/29/24 at 10:03 a.m. with CNA A, she revealed she should have changed her gloves during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A was asked why she did not change her gloves. She said she was nervous. CNA A stated she had infection control training (computer-based learning) about 2 weeks ago. She has been employed in the facility for 2 month and did not receive training with return demonstration from the facility. She said the resident could acquire an infection when she did not Page 1 of 2 675982 675982 04/01/2024 Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follow good infection control practices including not changing gloves before retrieving the resident's clean brief. During an interview with the RCN B on 04/01/24 at 4:58p.m., revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing or sanitizing hand and change of gloves before retrieving clean brief. RCN B noted the facility conducts yearly competency training and periodic in-services if needed. Review of the facility's Perineal care policy created 04/25/22 reflected: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident skin condition. Important Points: o If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care. o Do not wipe more than once with the same surface o Doffing and discarding of gloves are required if visibly soiled o Always perform hand hygiene before and after glove use 675982 Page 2 of 2