Avir At Sherman

designed to prevent the development and transmission of infection for one of five residents (Resident

providing incontinence care to Resident #1.

This failure could place the residents at risk for infection.Findings include: A record review of Resident #1's Quarterly MDS assessment, dated 12/30/25, reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included seizure disorder or epilepsy (A seizure is a single, temporary disruption of brain electrical activity, while epilepsy is a chronic neurological condition characterized by recurrent, unprovoked seizures), hypertension (elevated blood pressure), and depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical/cognitive symptoms that disrupt daily life for at least two weeks). Resident #1 had a BIMS score of 07 which indicated Resident #1's cognition was severely impaired. Resident #1 required substantial/maximal assistance of one-person physical assistance with toilet use and personal hygiene. An observation on 03/26/26 at 9:50 AM revealed CNA A entered Resident #1's room to answer the call light coming from the room's bathroom.

Resident#1 was standing next to the toilet holding the wall bar with his pants and brief down. CNA A washed her hands and put on a pair of clean gloves. CNA A cleaned the Resident buttock area and the tip of his penis using one wipe at a time. CNA A removed the old brief that was wet with urine. CNA A got a clean brief, and put it on Resident#1 without changing gloves or performing any form of hands hygiene (sanitizing/washing). CNA A helped Resident#1 pull up his pants, sit back in the wheelchair, wash his hands, and exit the bathroom. CNA A removed her gloves, exited the bathroom and put on clean gloves from a gloves box next to the exit door without any form of hands hygiene, and procced to make Resident#1's bed. CNA A gathered the dirty linens and trash, removed gloves, sanitized hands and exited the room. In an interview on 03/26/26 at 10:00 AM, CNA A stated she was to wash hands before and after care. CNA A also stated she was supposed to change gloves and complete hand hygiene before putting the clean brief on the resident. CNA A stated she did not complete hand hygiene or change gloves during the process because she was nervous. CNA A stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection. In an interview on 03/26/26 at 2:44 PM with the ADON, she stated during incontinent care, the staff were to change gloves, wash hands whenever moving from dirty to clean tasks.

She stated staff were to complete hand hygiene before putting on clean gloves and after removing gloves.

The ADON also stated that in between care, the CNA was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident.

The ADON stated the staff were to complete hand hygiene during care to prevent the spread of infection.

Record review of the facility's policy dated October 2023, and titled Hand Washing/ Hand Hygiene reflected, . it is the policy of this home that hand hygiene is the primary means to prevent the spread of infection.

Indications for Hand Hygiene.

Hand hygiene is indicated: a. immediately before touching a resident. d. after touching a resident. f. before moving from work on a soiled body site to a clean body site on the same resident; and. g. immediately after glove removal Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE