The Texas Department of State Health Services cited Hickory Trail Hospital because the facility “failed to provide a sanitary environment and implement proper infection control practices according to acceptable standards of care to avoid sources and transmission of infections and communicable diseases.” State surveyors found unsanitary conditions and surfaces in the patient care areas, including a “‘dirty'” gymnasium, a patient luggage room that was “‘not on a cleaning schedule,'” and housekeeping carts “soiled with grime and dust,” among others. State surveyors also observed several instances in which gero psychiatric unit staff failed to adhere to proper hand hygiene standards. In one case, a hospital staff member performed perineal care (cleaning of the inferior pelvic cavity) for a patient and touched the patient’s face and hair without changing gloves or hand washing. A second staff member who assisted on the perineal care, also failed to change gloves or perform hand hygiene before touching the patient’s bed, linens, wipe container, and wheel chair. Upon further review of the hospital’s infection prevention reports, state surveyors found that the hospital had one hospital-acquired genitourinary infection (UTI) for five consecutive months between September 2012 and January 2013. An interview with a staff member revealed that three out of the five patients with the hospital-acquired UTIs were treated in the gero psychiatric unit. As a result, Hickory Trail was required to submit a plan of correction to address its cited deficiencies including deficient infection control policies and practices.