Health inspection·August 24, 2024

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 Control Program designed to help prevent the development and transmission of disease for 2 (Residents #1 and Resident #2) of 8 residents reviewed for infection control during medication pass. Residents Affected - Few LVN A failed to remove her gloves and wash her hands before putting on a new set of gloves and after touching the peg tube of Resident #1, and then touching the gtube of Resident #2. These failures placed residents at an increased risk of exposure to infections, decreased quality of life or hospitalizations. Findings include: 1. Review of Resident #1's face sheet, dated 08/24/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] diagnosed with supraventricular tachycardia (erratic heartbeat), anoxic brain damage (occurs when the brain is deprived of oxygen), and personal history of traumatic brain injury. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS was not conducted because the resident was rarely/never understood). Section K Swallowing/Nutritional Status revealed feeding tube. Review of Resident #1's care plan revealed a focus of nothing by mouth due to dysphagia (difficulty swallowing). He was a high nutrition/hydration risk as dependent on PEG to meet all nutrition needs. 2. Review of Resident #2's face sheet, dated 08/24/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] diagnosed with reduction deformities of brain and cerebral palsy (damage to or abnormalities inside the developing brain that disrupt the brain's ability to control movement). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS was not conducted because the resident was rarely/never understood). Section K - Swallowing/Nutritional Status revealed feeding tube. Review of Resident #2's care plan revealed a focus of Resident #2 has potential for nutritional/hydration/aspiration risk due to G-TUBE in place for nutritional and hydration due to diagnosis of cerebral palsy and dysphagia. Page 1 of 2 455554 455554 08/24/2024 Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657

F 0880 Level of Harm - Minimal harm or potential for actual harm In an observation on 08/24/24 at 12:26 p.m., LVN took 2 sets of disposable gloves from the box and placed one set of gloves on her hands and pulled up Resident #2's clothing to expose the g-tube. LVN A touched Resident #2's g-tube. LVN did not remove the first set of gloves or wash her hands before putting on the second set of gloves. After touching Resident #1 she immediately she pulled up the clothing of Resident #1 to expose Resident #1's PEG and touched his PEG. Residents Affected - Few In an interview on 08/24/24 at 5:03 p.m., LVN A revealed she touched Resident #2's g-tube and his clothing and Resident #1's PEG tube and his clothing without using an alcohol-based hand rub or washing her hand in between changing her gloves. She revealed that the facility infection policy was to remove gloves and use and alcohol-based hand rub or wash hands before donning a second set of gloves and touching another resident. She revealed that if you do not wash hands or use an alcohol-based hand rub in between changing and touching other residents, residents can get sepsis and an infection. In an interview on 08/24/24 at 3:15 p.m., the DON revealed that staff had to absolutely wash hands in between removing gloves and donning a second set of gloves and touching another resident. If you do not wash hands, there could be cross contamination and residents could get an infection if are germs was passed from one resident to another. Review of facility policy on infection control dated 02/2012 reflected employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with the residents after removing gloves In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60 to 95% ethanol or isopropanol for all the following situations: before and after direct contact with residents before donning sterile gloves after contact with a residence's intact skin after removing gloves. 455554 Page 2 of 2