Health inspection·May 9, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, 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 disease and infection for 1 of 1 residents (Resident #6) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #6, CNA A did not change her gloves or wash her hands after touching the bed remote before starting to provide care. CNA B did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. CNA A changed gloves multiple times and did not sanitize between change of gloves. These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: Record review of Resident #6's face sheet, dated 05/09/2025, revealed an admission date of 09/12/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure) Record review of Resident #6's MDS Quarterly assessment, dated 03/23/2025, revealed the resident had a BIMS score of 7, indicating severe cognitive impairment. Resident #6 required total care with her activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #6's care plan revealed a care plan initiated 09/15/2023 with a problem of Resident is incontinent of bowel and bladder d/t impaired mobility., and an intervention of Check for incontinence routinely and PRN. Assist with incontinent care with each episode w/ use of skin barrier salve to promote skin integrity. Observation on 05/09/25 at 9:48 a.m., revealed while providing incontinent care for Resident #6, CNA A touched the bed remote with her gloved hands. CNA B touched the privacy curtain with her bare hands. Neither CNA A or CNA B changed their gloves or wash their hands, then, started to provide care for Resident #6. CNA A changed gloves multiple time while providing care but did not sanitize or wash her hands in between change of gloves. During an interview on 05/09/2025 at 10:05 a.m., CNA A and CNA B stated the privacy curtain and bed Page 1 of 2 676288 676288 05/09/2025 Avir at Cotulla 369 Mars Dr Cotulla, TX 78014

F 0880 Level of Harm - Minimal harm or potential for actual harm remote were considered dirty and they should have changed gloves and sanitize their hands. They revealed they did not realize they had to change their gloves and sanitize their hands before starting to provide the care. CNA A stated she did not use sanitizer between change of gloves multiple times and was unclear when to use sanitizer or wash her hands. They confirmed receiving training on infection control within the year. Residents Affected - Few During an interview on 05/09/2025 at 10:30 a.m., the DON stated the staff should have changed their gloves and sanitize their hands prior to start providing care for the resident. She stated they should sanitize their hands between change of gloves. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS. Record review of the facility's CNA A competency check titled, CNA proficiency audit, dated 09/13/24 revealed CNA A demonstrated competency in hand washing and incontinent care. Record review of the facility's CNA B competency check titled, CNA proficiency audit, dated 09/13/24 revealed CNA B demonstrated competency in hand washing and incontinent care. Review of facility policy, titled Handwashing/Hand Hygiene, dated 01/20/23, revealed Hand hygiene must be performed prior to donning (put on) and after doffing (remove) gloves. 676288 Page 2 of 2