Health inspection·May 7, 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 control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #117) observed for infection control. Residents Affected - Few The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #117 on 05/05/2025. These failures could place the residents at risk for infection. Findings included: Record review of Resident #117's face sheet dated 04/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Septic Arthritis to the left knee (bacterial infection in the knee joint) Record review of Resident #117's MDS admission Assessment, dated 04/16/25, revealed that the resident had a BIMS summary score of 15, which indicated that the resident was cognitively intact. Further review revealed that Resident #117 required supervision and touch assistance with toileting. Record review of Resident #117's comprehensive care plan revealed that the resident had an infection related to a compromised immune system and the presence of pathogenic microorganisms. Interventions included proper hand washing using antibacterial soap before and after each care activity and maintaining sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. During an observation on 05/05/25 at 10:21 AM, CNA B walked into Resident #117's room accompanied by CNA J. Both CNA B and CNA J washed their hands and donned (put on) their gown and gloves. CNA B performed catheter care on Resident #117, turned the resident to his right side, and wiped his buttocks three times. She removed the old brief, discarded it in the trash, and applied a new brief. CNA B used the same gloves and did not perform hand hygiene throughout the entire incontinent care process. They doffed (removed)their PPE and washed their hands. CNA B and CNA J thanked the resident and left the room. During an interview on 05/05/25 at 10:21 AM, CNA J said she was unsure why CNA B did not wash her hands or change her gloves while performing catheter care. She said the staff wereare in-serviced on washing their hands and changing gloves when going from dirty to clean. She said the risk of not washing hands and changing gloves during incontinent care could lead to cross contamination. She was Page 1 of 3 455770 455770 05/07/2025 Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469

F 0880 unable to recall the last time she was in-serviced on infection control when performing incontinent care. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/05/25 at 10:38 AM, CNA B said she was supposed to wash or sanitize her hands after providing catheter care and when applying a new brief. She said the staff should remove gloves, wash/sanitize their hands, and apply new gloves when going from a dirty brief to a clean brief. CNA B said she realized that she had not changed her gloves and had used the same gloves during the entire process after she had completed incontinent care. She said she had a skill check off on infection control and was educated on hand-hygiene and incontinent care during on-boarding. Residents Affected - Few CNA B said the risk of not changing her gloves and performing hand-hygiene could cause cross-contamination and infection. During an interview on 05/07/25 at 11:55 AM, the unit manager said she expected staff to follow standard precautions, and they should wash their hands before, during, and after providing incontinent/catheter care for all residents. She said the risk of not washing/sanitizing their hands could lead to cross-contamination and/or infection to all residents and staff. During an interview on 05/07/25 at 5:56 PM, the Quality Director said the staff should follow standard precautions and aseptic techniques when providing incontinent/catheter care. She said the staff should wash their hands before placing clean gloves on and wash hands before, during, and after all procedures. The Quality Director said the risk could be infection to other residents and themselves. She said she would be performing re-education and skills checkoff for infection control and incontinent care with all staff. Record review of the facility policy on Infection Control dated 11/2001 (Revised 6/2024) read in part .A. Standard Precautions--Standard Precautions combines the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances)and applies them to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status. Standard precautions apply to: · blood, · all body fluids, secretions, and excretions regardless of whether or not they contain visible blood, · non-intact skin, and · mucous membranes. 455770 Page 2 of 3 455770 05/07/2025 Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469

F 0880 Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455770 Page 3 of 3