OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#4) whose ADL care was observed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2022 with diagnoses including history of myocardial infarction (heart attack). The resident was dependent on staff for all ADL care, including incontinence care, grooming, and hygiene. a. At 11:40 am on 09/08/26, Staff 20 (MT/CG) and Staff 11 (CG) were observed providing incontinence care for Resident 4 in his/her bed. Staff 20 and Staff 11 donned gloves, removed the resident’s soiled brief, and provided perineal care. They did not remove their soiled gloves and don clean gloves prior to beginning clean tasks, including putting a clean brief on the resident. Both staff members continued to wear their soiled gloves while assisting the resident to sit, applying a gait belt, transferring the resident with two-person assistance to his/her wheelchair, and removing the gait belt. Staff 20 was observed holding the resident’s hand while wearing soiled gloves. The staff members then removed their soiled gloves but did not complete hand hygiene. Staff 11 escorted the resident in his/her manual wheelchair to the dining room and did not complete hand hygiene prior to preparing and serving a cup of coffee to the resident. b. At 11:45 am on 09/10/26, Staff 13 (MT/CG) and Staff 14 (CG) were observed providing incontinence care to the resident in his/her bed and while seated in his/her manual wheelchair in the bathroom. Staff 13 and Staff 14 donned gloves, removed the resident’s soiled brief, and provided perineal care for a bowel movement. They did not remove their dirty gloves and don clean gloves prior to rolling the resident to his/her side, including touching his/her arms, hands and shirt, putting a clean brief and clean pants on the resident, moving Resident 4’s call pendant from the bed to the side table, or prior to transferring the resident with two-person assistance and use of a gait belt to his/her wheelchair. Staff 13 removed a soiled incontinence pad from the bed and placed it on the floor. Upon realizing the resident’s bedding and new pants and brief were soiled again, the resident was wheeled into his/her bathroom and staff continued to provide incontinence care. The resident was assisted to stand and returned to sitting multiple times while staff assisted in removing his/her soiled pants and brief, completed perineal care and put a clean brief and pants on the resident. The resident sat without a barrier between his/her skin and the soiled incontinence pad in his/her wheelchair before and after peri care, and while wearing both soiled clothing and brief and clean clothing and brief. Staff did not change gloves between dirty and clean tasks. After the incontinence care was completed, Staff 13 continued to wear soiled gloves while removing the resident’s gait belt and placing it on his/her own waist and touching the resident’s personal items. The staff member then proceeded to remove his/her soiled gloves but did not complete hand hygiene, and brushed the resident’s hair, placed the call pendant around his/her neck, and escorted the resident to the dining room. The resident’s hands were not washed prior to the resident eating his/her meal, despite care staff holding her hand with soiled gloves during the incontinence care process. The need to maintain infection prevention and control protocols was reviewed with Staff 1 (Administrator), Staff 2 (Regional Operations Manager), and Staff 3 (RN) on 09/10/26 at 12:45 pm. They acknowledged the findings, and no additional information as provided.

All staff will be in-serviced with appropriate procedure on infection control when providing resident care. The skills checklist has been updated to include the Resident Coordinator Observation of tasks signature that states she has personally observed such tasks being done correctly. Community Infection control specialist will ensure observations are completed upon hire and quarterly for each employee and as needed if corrective action is required.