Health inspection·June 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **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 along with to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 4 residents observed for infection control. The facility failed to remove soiled bed linens from Resident #1's bed. This failure could place residents at risk for the spread of infection. Findings included: Observation on 6/27/23 at 9:57am during the surveyor's initial observation of the Alzheimer unit, surveyor smelled a foul odor and observed multiple dry brown stains covering a large portion of the sheet on the Resident #1's bed sheets. Record review of Resident #'1's face sheet revealed a [AGE] year-old female with a current admit date of 2/3/2021. Her diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbances, unsteadiness on feet, generalized anxiety disorder, muscle weakness, cognitive communication deficit, delusional disorders, and major depressive disorder. Record review of Resident #1's MDS dated [DATE] revealed resident was unable to complete a BIMS due to cognitive impairment. The MDS revealed the resident required extensive assistance from staff with transfers, bed mobility, transfers, dressing, toileting, and personal hygiene. Interview with Aide A assigned to Resident #1's room on 6/27/23 at 1:06pm, revealed the resident was incontinent of bowel and bladder. Aide A revealed the aides are responsible to change linens. Aide A revealed she was unaware of when Resident # last slept in the bed and when Resident #1's room was last cleaned. Aide A revealed when a resident's bed had soiled linens the soiled linens needed to be taken off, the Aide needed to clean the bed and then make the bed. Aide A revealed the risk of leaving soiled linens on a bed could cause a resident to be sick. Aide A revealed the linens were changed routinely and as needed. Aide A revealed the residents that were on hospice had a hospice aide that came Monday-Friday for showers and changed the bed linens. Interview with LVN on 6/27/23 at 1:15pm LVN revealed Resident#1 was bowel and bladder incontinent. LVN revealed the aide was responsible daily to change the bed linens, but ultimately everyone was responsible to change the bed linens. The LVN revealed the resident last slept in her bed on 6/23/23 Page 1 of 3 455904 455904 06/27/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0584 Level of Harm - Minimal harm or potential for actual harm prior to going to the hospital. The LVN revealed if a resident goes to the hospital all lines are taken off the resident's bed and clean linens are put on the bed. The LVN revealed she made sure herself to change the linens when Resident #1 left for the hospital on 6/23/23. The LVN revealed the resident would return to the same bed. The LVN revealed the risk of leaving soiled linens could be bacteria, wounds, infections, skin compromised, hygiene issues. Residents Affected - Some Interview on 6/27/23 at 1:45pm the DON revealed Resident #1 was assigned to bed 522B, but she was currently in the hospital. The DON revealed Resident #1 went to the hospital on 6/23/23. The DON revealed Resident #1 had a roommate. Resident #1 had a roommate, but the roommate was asleep each time surveyor attempted to interview her. The DON revealed Resident #1 was incontinent of bowel and bladder. The DON revealed the aides and LVNs are responsible to change the bed lines each morning and as needed. The DON revealed the last time Resident #1 slept in her bed was the night before she went to the hospital. The DON revealed the risk of leaving soiled bed linens on beds could cause infection control issues. The DON revealed the LVNs do their rounds each shift and the management team does rounds each morning. Record review of the facility Policy for Infection Control Prevention and Control Program dated, 9/2017 revealed in part: Policy Statement The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Goals: The goals of the Infection Control Program are to: a. Decrease the risk of infection to residents and personnel. b. Recognize infection control practices while providing care. c. Identify and correct problems relating to infection control practices. d. Ensure compliance with state and federal regulations relating to infection control. e. Promotion individual resident's rights and well-being while trying to prevent and control the spread of infection. 455904 Page 2 of 3 455904 06/27/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0584 f. Level of Harm - Minimal harm or potential for actual harm Monitor employee health and safety. Residents Affected - Some 455904 Page 3 of 3