Health inspection·August 8, 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 control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 3 or 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control.1. CNA A failed to change gloves when providing incontinent care to Resident #1 on 08/07/25.2. CNA B failed to conduct hand hygiene between glove changes and wiped from back to front while providing incontinent care to Resident #2 on 08/07/25.3. LVN C failed to change gloves after touching a soiled brief and before applying a clean brief to Resident #3 on 08/07/25.Thes failures could place incontinent residents at risk for infection.The findings included:1. Review of Resident #1's face sheet, dated 08/07/25, reflected an [AGE] year-old female admitted to the facility 05/14/24. Her diagnoses included cerebrovascular disease (a group of conditions that affect blood flow to the brain), Alzheimer's disease (a type of dementia), muscle weakness, and type 2 diabetes (a condition that affects the way the body processes blood sugar). Review of Resident #1's annual MDS assessment, dated 05/23/25, reflected a BIMS score of 8 which indicated moderately impaired cognition. The MDS reflected she required substantial/maximal assistance for toileting hygiene. The MDS reflected she was frequently incontinent of both bladder and bowel. Review of Resident #1's comprehensive care plan, revised on 08/01/25, reflected in part, Focus - The resident has bladder incontinence. Goal - The resident will remain free from skin breakdown due to incontinence. Interventions - Check the resident as needed and as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN after incontinence episodes. An observation and interview on 08/07/25 at 9:53 AM revealed CNA A assisted Resident #1 as she transferred from the wheelchair to bed. Resident #1 stated she had just changed her brief and did not need assistance, but then stated she was wet and did not understand what had happened. Resident #1 removed her pants as CNA A washed his hands and donned (put on) clean gloves. After CNA A assisted Resident #1 to lay on her back, he opened the front of the brief. He retrieved a clean wipe from the package and cleaned the suprapubic area. He disposed of the wipe, retrieved a clean wipe from the package, and wiped from front to back on one side of the perineum then disposed of the wipe. He retrieved another clean wipe and wiped the other side of the perineum. He retrieved another wipe from the package and wiped between the labia. The resident turned onto her right side. CNA A continued the process of cleaning the buttocks while using a clean wipe for each swipe. CNA A picked up the soiled brief and placed it in the trash. CNA A, without changing gloves, placed a clean brief under the resident, assisted resident to turn and finished fastening the new brief on the resident. CNA A then removed his soiled gloves and washed his hands. During an interview on 08/07/25 at 10:00 AM, CNA A stated he was supposed to wash his hands before and after every resident contact. He stated he had been in-serviced on infection control and he was told about PPE. He stated not wearing PPE or washing hands properly could spread germs. 2. Review or Resident #2's face sheet, dated 08/07/25, Residents Affected - Some Page 1 of 3 455799 455799 08/08/2025 Austin Wellness & Rehabilitation 11406 Rustic Rock Drive Austin, TX 78750

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected a [AGE] year-old female originally admitted to the facility 11/12/19, and readmitted [DATE]. Her diagnoses included other frontotemporal neurocognitive disorder (a group of conditions that weaken a person's mental functions), dementia, unsteadiness on feet, and other lack of coordination. Review of Resident #2's quarterly MDS, dated [DATE], reflected the resident was not able to participate in a BIMS process. Staff assessed the resident with impaired short- and long-term memory impairment. The MDS reflected Resident #2 required substantial/maximal assistance for toilet hygiene. The MDS reflected Resident #2 was frequently incontinent of bladder and bowel. Review of Resident #2's comprehensive care plan, revised 1/29/25, reflected in part, Focus - Resident has an ADL self-care performance deficit r/t dementia. Goal - Resident will maintain current level of function. Interventions/Tasks - Toilet Use - Resident is total dependent for toilet use/incontinent care. An observation on 08/07/25 at 10:22 AM revealed CNA B as she prepared to perform incontinent care for Resident #2. Resident #2 was lying supine (on her back) in bed. CNA B explained her intention to perform incontinent care, but the resident did not verbalize a response. CNA B went into the bathroom, and washed her hands, then came out and donned clean gloves. CNA B tucked the front of the soiled brief between the resident's legs. CNA B performed incontinent care using one cleaning wipe for one swipe, front to back. CNA B assisted Resident #2 to turn to her left side, where the resident's buttocks were now exposed. CNA B removed her soiled gloves, and without hand hygiene, put on clean gloves. CNA B used three more clean wipes, each for one swipe, swiping from back to front. CNA B positioned a clean brief under the resident. CNA B removed her soiled gloves and without hand hygiene, donned clean gloves. She placed the soiled brief in the trash then assisted the resident to position and finished applying the clean brief. She positioned the resident and lowered the bed. CNA B, without hand hygiene, changed her gloves and gathered the trash. She removed her gloves then went to the bathroom and washed her hands. During an interview on 08/07/25 at 10:32 AM, CNA B stated she was recently in-serviced on infection control. She stated she learned about wearing the right PPE when providing care. She stated she was trained to wash her hands at before providing care and when she finished care. She stated she usually used sanitizer on her hands every time she changed gloves, but she had forgotten to take her bottle of sanitizer into the room today. CNA B stated not performing proper hand hygiene or not wearing proper PPE could cause you to get or spread infection. During an interview on 08/07/25 at 10:35 AM, policies for incontinent care, hand hygiene, and the use of gloves were requested from the DON. The DON stated he would look for the policies. During an interview on 08/07/25 at 11:08 AM, the ADM provided a policy for perineal care. He stated the policy said to wash hands after removing gloves before putting on new gloves. He also said the policy reflected the correct procedure was to wipe from front to back. He stated they had already started to in-service the staff. 3. Review of Resident #3's face sheet, dated 08/07/25, reflected a [AGE] year-old female originally admitted to the facility 04/18/25 and readmitted on [DATE]. Her diagnoses included benign neoplasm (a noncancerous tumor) of pituitary gland (a gland that releases hormones that control multiple body functions), type 2 diabetes (a condition that affects the way the body processes blood sugar), muscle weakness, and cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit). Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 9 which indicated moderately impaired cognition. The MDS reflected Resident #3 required partial/moderate assistance with toileting hygiene. The MDS reflected Resident #3 was always incontinent of bladder and bowel. Review of Resident #3's comprehensive care plan, revised 04/05/25, reflected in part, Focus - The resident has bowel incontinence. Goal - The resident will have less than two episodes of incontinence per day through the review date. Interventions/Tasks - Provide peri care after 455799 Page 2 of 3 455799 08/08/2025 Austin Wellness & Rehabilitation 11406 Rustic Rock Drive Austin, TX 78750

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some each incontinent episode. During an observation on 08/07/25 at 11:14 AM, Resident #3 stated LVN C could provide incontinent care. LVN C washed her hands and donned clean gloves. LVN C adjusted the bed height and the covers. LVN C opened the front of the brief and pushed the brief between the resident's legs. LVN C used one wipe for each swipe, cleaning from front to back. LVN C assisted Resident #3 to roll to her left side. LVN C continued and cleaned the resident's back side, wiping from front to back. LVN C rolled up the soiled brief leaving it next to the resident's buttocks. LVN C doffed (removed) her gloves, sanitized her hands then donned clean gloves. She placed a clean brief between the resident's buttock and the soiled brief. The clean brief touched the soiled brief. LVN picked up the soiled brief and placed it in the trash. Without changing the now soiled gloves, LVN C applied the clean brief. LVN C doffed the gloves and washed her hands. CNA B assisted LVN C as they repositioned Resident #3 in the bed. During an interview on 08/07/25 at 11:21, LVN C stated she had been trained on infection control sometime in the middle of the last month. She stated hand hygiene was required before and after providing care. She stated hand hygiene was performed with each glove change. LVN C stated gloves should be changed when going from dirty to clean. She stated not performing hand hygiene or wearing proper PPE could lead to the spread of infection. During an interview on 08/07/25 at 11:37 AM, the ADM stated he expected staff to perform proper hand hygiene and to follow the policies and procedures. The ADM stated the nurses were responsible for monitoring the CNAs to ensure they followed the correct procedures. He stated the DON also monitored the CNAs and the nurses. During an interview on 08/07/25 at 11:48, the DON stated he expected appropriate care, and that staff followed the infection control guidelines. He stated he expected that staff understood why things like peri-care were done a particular way. He stated they did annual competencies, and all staff were checked off during orientation when hired. The DON stated he made observations of care periodically but mostly the nurses monitored the CNAs. The DON stated not following infection control guidelines could transfer bacteria and cause infection including sepsis. No policies for Hand Hygiene or the use of gloves were received prior to exit from the facility. Review of the facility Perineal Care, revised 06/2020, reflected in part, Purpose - To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Procedure - I. Wash hands. V. put on gloves. VI. Wash the pubic area. A. For female residents: i. Wash with soapy washcloth/cleansing wipe, moving from front to back, on each side. ii. Rinse area, moving from front to back. VII. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area . XII. Remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves. XII. Put on clean gloves. Placed soiled linen in proper container. 455799 Page 3 of 3