Health inspection·May 20, 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 diseases and infections for 2 of 13 residents (Resident #1 and Resident #2) observed for infection control. Residents Affected - Some 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to his wounds and foley catheter during a wound care observation on 05/20/25. 2. The facility failed to ensure Agency CNA C performed hand hygiene while providing incontinence care to Resident #2 on 05/20/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1.Record review of Resident #1's undated face sheet reflected a [AGE] year-old male with an admission date of 01/15/25 and a readmission date of 05/07/25. Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected resident had a BIMs of 15 which indicated he was cognitively intact, had a foley catheter and was always incontinent of bowel. Diagnosis included: septicemia (a systemic infection where bacteria invade the bloodstream), paraplegia (loss of motor and sensory function in both legs), and pressure ulcers of sacral area (area at the base of the spine) An observation on 05/20/25 at 9:55 a.m. of wound care revealed RN A outside of Resident #1's room preparing supplies needed for the resident's wound care. An EBP (Enhanced Barrier Precautions) sign was posted outside of the room next to the door. There was no supply of PPE observed outside of the room or inside of the room. RN A sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. RN A entered the room, performed hand hygiene, and put on gloves, but did not put on a gown. RN A proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. After completion of wound care, RN A retrieved the resident's wheelchair. RN A emptied Resident #1's urinary drainage bag, and then assisted him into his wheelchair. RN A gathered the trash, removed her gloves, and performed hand hygiene and left the room. In an interview with RN A on 05/20/25 at 11:00 a.m. who stated any resident with wounds and a foley Page 1 of 3 455806 455806 05/20/2025 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0880 Level of Harm - Minimal harm or potential for actual harm catheter were supposed to be in Enhanced Barrier Precautions. She stated she should have worn a gown when she entered the room. She stated she did not see any PPE outside of the room, which was why she probably overlooked it. RN A stated she was not sure why there was no PPE outside of his room. RN A stated someone must have moved it because he had been in EBP since his admission. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. Residents Affected - Some In an interview with the DON on 05/20/25 at 4:35 p.m. she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explains what PPE was to be worn and for what task the PPE is to be worn for. She stated any contact with a resident with a wound or a catheter required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions. She stated there should have been PPE outside of Resident #1's room. She stated she was not sure who moved it but would make sure all of the residents who were on EBP had the necessary supplies for the staff. 2. Record review of Resident #2's MDS, dated [DATE], reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Muscle wasting and atrophy (gradual decline in body tissue), Dementia and Alzheimer's disease. Resident#2 had a BIMS score of 05 which indicated severe cognitive impairment. His Functional status reflected he was dependent on staff for toileting hygiene including incontinent care. Record review of Resident #2's care plan, dated 03/31/25, reflected Problem. Category: ADLs Function Status [Resident#2]'s ADL functions . Toileting . Goal: [Resident#2] will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Approach: Assist with ADLs as needed . Observation on 05/20/25 at 10:37 a.m. of Resident #2's incontinent care, provided by Agency CNA C, and CNA D, revealed Resident#2 was on his bed asleep. Both CNAs entered Resident#2's room, CNA D awakened Resident #2, explained to him the procedure and adjusted the bed. Both CNAs washed their hands and put on gloves. CNA D folded Resident#2 cover toward the foot of the bed, pulled his pants down, and unfasten the brief. CNA D then instructed and assisted Resident#2 to roll towards her. Agency CNA C then clean the Resident's buttocks area using one wipe per stroke. Agency CNA C removed the soiled brief and threw it in the trash can, and then removed the under pad and put it in a separate plastic bag. Agency CNA C changed her gloves without performing hand hygiene. Agency CNA C then placed the new brief and clean under pad under the Resident's buttocks. CNA D rolled the Resident to the other side and adjusted the under pad and brief. Both CNAs then assisted the resident onto his back. Agency CNA C cleaned Resident #2 groin area using one wipe per stroke. CNA C changed gloves without performing hand hygiene. Both CNAs fastened the brief, then pulled Resident #2's pants up and pulled the blanket to his chest. Both CNAs removed their gloves and washed their hands. CNA D took the plastic bags and disposed of them in the dirty linen room in the hallway. Interview on 05/20/25 at 10:47 a.m., CNA C acknowledged she had changed her gloves without performing hand hygiene during Resident#2 incontinent care. CNA C stated she was supposed to follow proper hand hygiene and should have cleaned the resident's groin area before the buttocks. She emphasized that adhering to proper hand hygiene and correct perineal care procedures was important to prevent the spread, and development of infection to residents. In interview on 05/20/25 at 3:07 p.m. the DON stated infection control was important during residents' care. The DON stated during care the staff were to use the hand sanitizer or wash their hands if 455806 Page 2 of 3 455806 05/20/2025 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer. The DON stated hand hygiene was to be completed for infection control. The DON stated staff were trained to follow proper steps during residents' care to prevent cross contamination. Record review of the Facility's policy titled, Isolation Precautions including Standard/Universal Precautions, and Enhanced Barrier Precautions, revised August 2022, reflected, Enhanced Barrier Precautions (EBPs) .expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP will be implemented for All residents with the following .Wounds and/or indwelling medical devices .urinary catheter .regardless of MDRO colonization status .The facility will post signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves) .The facility will provide gowns and gloves immediately outside of the resident' room and position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care another resident in the same room . Record review of the facility's policy titled, Hand Hygiene/Handwashing, dated May 2023, reflected, .Hand Hygiene/Hand washing is the most important component for preventing the spread of infection .Hand Hygiene/Hand Washing is done before: .resident contact before performing an aseptic task After .contact with soiled or contaminated articles, such as articles that are contaminated with body fluids .resident contact .assisting other with toileting .after removal of medical /surgical or utility gloves . 455806 Page 3 of 3