Health inspection·February 13, 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 observations, interviews, and record reviews, the facility failed to establish and 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 for 1(Resident #1) of 2 residents reviewed for infection control practice, in that: Residents Affected - Some 1) CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. 2) LVN A failed to perform hand hygiene and change gloves while providing wound care. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 02/13/24, revealed the resident was an 82- year- old female admitted to the facility on [DATE] with diagnoses of personal history of Covid-19, acute candidiasis of vulva and vagina (Fungal infection), and Alzheimer's disease. Review of Resident #1's MDS assessment, dated 11/27/22, revealed Resident #1 required total assistance with most activity of daily living (ADLs) and two-person assist. Resident #1 was frequently incontinent of bowel and always of bladder. Review of Resident #1's care plan, dated 10/30/22, revealed the resident was care planned for being incontinent of bladder and bowel related to impaired cognition and mobility. Observation of incontinence care for Resident #1 on 02/12/24 at 10:32 a.m. revealed CNA C and CNA D was about to transfer the resident from wheelchair to bed when the surveyor entered the room. Both used proper transfer technique to move the resident. Both CNA C and CNA D did change gloves after transferring Resident #1. CNA C removed the resident's soiled brief. She wiped from front to back. Resident #1's brief was soiled with urine and fecal matter. Both repositioned Resident #1. CNA C continued to clean the resident bottom area. CNA C gloves were visibly soiled with urine. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. CNA C applied skin protector on the resident perineal area with same soiled gloves. She placed the clean brief on the resident and fastened it. Meanwhile, CNA D was assisting CNA C to provide care to Resident #1. CNA D wore the same gloves for transferring and repositioning the resident including touching the perineal area and fastened the clean brief to the resident. CNA C and CNA D did not wash their hands before exiting Resident #1's room. Page 1 of 3 455849 455849 02/13/2024 Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230

F 0880 Level of Harm - Minimal harm or potential for actual harm In an interview on 02/12/24 at 10:48a.m with CNA C she stated she had been employed at the facility for 2 years and received infection control in-services 4 months ago. CNA C stated cross contamination meant mixing clean with dirty. CNA C stated she should have washed hands and changed gloves before retrieving the resident clean brief. She noted Resident #1 could get an infection for not using good infection control practice. Residents Affected - Some Interview with CNA D on 02/12/24 at 10:52a.m revealed she had been employed at the facility since May 2023 and received infection control training on orientation. She stated cross contamination was transferring germs from one place to another. CNA D stated she should have changed her gloves and washed her hands before fastening Resident #1clean brief. She noted Resident #1 could get sick for not washing hands or changing gloves. Review of physician orders for February 2024 reflected, Sacrum-Apply hydrocolloid dressing FOR MASD (moisture-associated skin damage), every day shift every Monday, Wednesday, Friday. Observation of pressure ulcer on Resident #1 on 02/12/24 at 11:04 a.m. revealed LVN A did not wash his hands but donned gloves before the start of care. He prepared a clean field on a paper spreader. LVN A removed old dressing revealing a thin clear dry wound on the coccyx with granulation (healing) around the wound bed. LVN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean dressing and placing on Resident #1's wound. LVN A picked it up the trash and walked out of the room without washing hands. In an interview on 02/12/24 at 11:12 a.m. with LVN A, he revealed he should have washed his hands before starting care and changed his gloves during care. LVN A also revealed she should have changed his gloves before retrieving a clean dressing and placing on Resident #1's wound. LVN explained he had been employed in the facility since August 2023 and received infection control training during orientation. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. During an interview with the DON 02/12/24 at 11:20a.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the staffs were expected to wash hands don gloves before starting care. Review of the facility Hand hygiene policy implemented 11/12/17 reflected, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection t other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1) Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2) Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice. 455849 Page 2 of 3 455849 02/13/2024 Advanced Rehabilitation and Healthcare of Bowie 700 W Highway 287 S Bowie, TX 76230

F 0880 3) Level of Harm - Minimal harm or potential for actual harm Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. Residents Affected - Some a) Hands are visibly dirty. b) Hands are visibly soiled with blood or other body fluids. c) Before and after eating . d) Between resident' contacts. 455849 Page 3 of 3