Health inspection·January 10, 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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. Residents Affected - Few The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 01/10/25, revealed a 67- year- old female admitted to the facility on [DATE] with diagnoses including frequency of micturition (urinating), constipation, muscle weakness and Alzheimer's disease (neurological disorder). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder. Observation of incontinence care for Resident #1 on 01/09/25 at 2:55p.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and placed it on the bed close to resident. She did not completely remove it. CNA A wiped the resident from front to back. She retrieved a clean brief and placed it on top of the soiled brief. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A changed her gloves, and retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room. In an interview on 01/09/24 at 3:06 p.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training last month. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was not thinking. Page 1 of 2 455915 455915 01/10/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0880 Level of Harm - Minimal harm or potential for actual harm During interview on 01/10/25 at 5:11 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The ADON trained and monitored staffs with return demonstration periodically. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She stated the corporate nurse also trained staff annually. Residents Affected - Few Review of the facility's infection control policy dated 04/27/22 reflected: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Important Points: o Doffing and discarding of gloves are required if visibly soiled o Always perform hand hygiene before and after glove use 455915 Page 2 of 2