Health inspection·March 30, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, 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 3 residents (Resident #3) reviewed for infection control: Residents Affected - Few The facility failed to ensure CNA A changed her gloves and washed or sanitized her hands after they became contaminated during incontinent care, before touching Resident #3's clean linen and clean brief. This failure could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #3's admission Record (face sheet) dated 03/30/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a progressive decline in memory, thinking, reasoning and problem-solving that interferes with daily life activities), vitamin D deficiency (inadequate intake of a mineral that can lead to a loss of bone density), schizophrenia (a chronic and severe mental disorder characterized by a disconnection from reality, often involving hallucinations, delusions, and disorganized thinking or behavior), bipolar disorder (a chronic mental disorder with extreme shifts in mood and behavior), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest), and high blood pressure. Record review of Resident #3's most recent Quarterly MDS Assessment, dated 02/15/2025, revealed a BIMS score of 15 out of 15 indication her cognitive skills for daily decision making were intact, required substantial/maximal assistance with toileting and was always incontinent of bowel and bladder. Record review of Resident #3's Care Plan for ADL Self Care Performance Deficit, initiated 06/18/2020, revealed under interventions the resident required assistance of 2 staff for toileting. Observation on 03/26/2025 from 2:38 p.m. to 3:00 p.m. of CNA A and the DON provide incontinent care to Resident #3 revealed CNA A wiped the resident's front perineal (region located between genitals and the anus) area, then with the same soiled gloves, touched the bed linen without changing her gloves. CNA A then provided pericare (washing the genitals and anal area) to the resident's buttocks, removed the soiled brief, removed the soiled gloves, and used sanitizer. The CNA put on clean gloves and wiped fecal material from Resident #3's legs with her gloved hands, then with the same soiled gloves CNA A touched the resident, rolled the resident to her back, and continued to cleanse the Page 1 of 2 455444 455444 03/30/2025 Mesa Vista Inn Health Center 5756 N Knoll Dr San Antonio, TX 78240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's legs from the front. CNA A then touched Resident #3's clean brief with the same soiled gloves used to wipe fecal material from the resident's legs. In an interview on 03/26/2025 at 3:02 p.m. CNA A stated she had received training in December 2024 on the correct way to do perineal care. CNA A stated if her gloves were soiled with poop (fecal material) she would change her gloves and if she had cleaned a resident's perineal area, she would change her gloves before she touched the resident. CNA A stated she did not remember touching Resident #3 with her soiled gloves during the incontinent care the surveyor observed. In an interview on 03/30/2025 at 2:34 p.m., the DON stated when she assisted CNA A provide incontinent care to Resident #3, she did not notice CNA A had touched the resident's bed linen, the resident, and the resident's brief with soiled gloves. The DON stated she tried to assist the CNA with repositioning the resident as much as she could during the incontinent care. In an interview on 03/26/2025 at 4:32 p.m., the DON stated the facility's policy was to change gloves when they were visible soiled or if the staff thought the gloves were soiled, and when they were done with the perineal care before putting on clean brief or clothes on the resident. The DON stated she would expect the nursing staff to perform hand hygiene after incontinent care was performed before they touched the resident, linens, or brief. Record review of the facility's undated policy on Hand Hygiene revealed hand hygiene should be performed before and after assisting a resident with personal care, after contact with a resident's body fluids or excretions, after removing gloves, and after handling soled or used linens, dressings, bedpans, catheters, and urinals. Record review of the facility's Infection Control Plan: Overview policy, dated 2019, revealed The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Under Preventing Spread of Infection was (3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Under Intent was Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination; and properly .handle, process and transport linens to minimize contamination. 455444 Page 2 of 2