Health inspection·April 9, 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 observations, interviews and record reviews, 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 diseases and infections for 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care. Residents Affected - Some The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2. These failures placed residents of the facility at risk of infections from incontinent care. Findings included: Resident #1 Record Review of resident #1's Face Sheet dated 01/10/2025 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), and Lack of coordination. Record review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 06 (severe cognitively impairment). Section H-Bladder and Bowel, resident always incontinent. During an observation on 04/08/2025 at 2:35 PM, CNA-A and CNA-C performed peri-care for Resident #2. CNA-A folded each wipe and reused the folded wipe on the resident. CNA-A also did not pull back and clean the resident's foreskin while performing pericare. During an interview on 04/08/2025 at 2:55 PM, CNA-A stated she had not performed pericare correctly because she folded the wipes and reused. She stated she also had not pulled back the resident foreskin and cleaned it incorrectly. CNA-A stated in not doing so could have caused buildup and lead to an infection. During an interview on 04/08/2025 at 3:00 PM, the DON stated, pericare should have been performed using one wipe, one swipe technique. She stated the wipes were not to be folded. The DON stated pericare should have begun with pulling back the foreskin of the resident and in not doing so, could have resulted with a resident infection. Resident #2 Page 1 of 3 455744 455744 04/09/2025 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of resident #2's Face Sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #2's diagnoses revealed: Diabetes Mellitus, Generalized edema (swelling), Peripheral vascular disease, and noncompliance. Record review of Resident # 2's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent. During an observation on 04/08/2025 at 4:19 PM, CNA-A and CNA-B performed pericare for Resident #2 and began from back to front of resident. During an interview on 04/08/2025 at 4:45 PM, the DON stated, for male residents that were uncircumcised, staff should have pulled the foreskin back and clean and returning the foreskin afterward. She stated she had trained her staff to use the one wipe, one swipe method for all residents. She stated all pericare should have begun from front to back. The DON state it was the DON who monitored with random checkoffs and quarterly. She stated the negative impact of not having pulled back the foreskin and not having performed the one wipe one swipe on residents was possibly infection and a possible uti (urinary tract infection). She stated biggest concern for her was the foreskin not being retracted and could have caused a significant infection. The DON stated she in serviced the staff on pericare just a couple of weeks ago. She stated her expectations was for staff to perform pericare correctly every time whether they was being watched or not. The DON stated the failure occurred the with the staff not having followed the policy on how pericare was to be provided. Record review of the CNA-A, CNA-B, and CNA'C's Pericare competencies revealed: CNA-A dated 03/17/2025 with all pericare skills having been met. CNA-B dated 03/25/2025 with all pericare skills having been met. CNA-C dated 03/25/2025 with all pericare skills having been met. Record review of the facility policy titled Perineal Care with a revised date of February 2018 revealed: Male 1. Follow steps below: Take the wipe in one hand and gently grasp the penis shaft. If, the resident is uncircumcised gently pull back the foreskin and wipe the head of the penus beginning at the urethral opening working outward and away from the penis head (circular motion). Use new wipe with each stroke. After cleaning is complete gently move the foreskin back into it's natural position if uncircumcised. 455744 Page 2 of 3 455744 04/09/2025 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0880 Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Level of Harm - Minimal harm or potential for actual harm Using a new wipe with each stroke clean from the upper part of the leg to the hip. Repeat on the other side and then once from hip bone to hip bone. Residents Affected - Some Turn the resident over and repeat on the back side 455744 Page 3 of 3