Health inspection·May 31, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 one resident (Resident #1) of three residents, reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure CNA A and CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 04/14/25, reflected he had had a BIMs score of 15 and was cognitively intact The MDS reflected that Resident #1 had the following diagnoses diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, chronic obstructive pulmonary disease (COPD) (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction). The resident was occasionally incontinent of bowel and bladder. The functional abilities of the resident were documented as dependent for toileting. Review of Resident #1's Comprehensive Care Plan, edited dated 02/026/25, reflected the resident had an activities of daily living selfcare deficit requires assistance setup/supervision, resident ability fluctuates related to shortness of breath. Facility interventions included: provide necessary equipment and adequate time for self-performance or participate with daily care. An observation on 05/31/25 at 11:21am revealed Resident #1 was in electric wheelchair. He was awake, alert, and oriented. CNA A and CNA B transferred resident to bed and prepared to perform incontinence care for the resident. Resident#1 had a bowel movement and brief was wet. CNA A performed peri-care and cleaned the front including his penis. CNA B performed peri-care and cleaned the buttocks. CNA A and CNA B did not change gloves or perform hand hygiene. CNA A and CNA B put a clean brief on the resident and covered him with the linens. CNA B put dirty diaper in plastic trach bag and removed gloves CNA A moved residents table arranged his personal belongings on his bedside table to include his water pitcher then removed gloves. An interview on 05/31/25 at 12:36pm revealed CNA B knew that she was supposed to change gloves and perform hand hygiene but did not want to because she was moving fast and the surveyor was watching her she got nervous. Page 1 of 2 676132 676132 05/31/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 05/30/25 at 1:41pm revealed CNA A knew that she was supposed to change gloves and perform hand hygiene but did not want to because she only cleaned the front if she cleaned the buttocks she would have changed her gloves before applying the clean brief. An interview on 05/31/25 at 1:03pm with the Infection Preventionist revealed staff were supposed to clean a resident, change gloves, perform hand hygiene, and then put a clean brief on the resident. The Infection Preventionist said failure to change gloves and perform hand hygiene could cause issues with infection control. An interview with the DON on 05/31/25 at 3:34 PM revealed staff were supposed to change their gloves and perform hand hygiene after cleaning a resident. The DON said failure to do so could cause infection. Review of facility policy titled Handwashing/Hand Hygiene last updated 01/2025 reflected the following: This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol -based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility 676132 Page 2 of 2