Health inspection·June 12, 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 CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 06/11/2025. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 06/12/25, revealed a 78- year- old female admitted to the facility on [DATE] with diagnoses including age-related debility (physical and mental weakness), muscle weakness, muscle wasting and atrophy (partial or complete wasting away of the body). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required partial/moderate assistance with most activities of daily living (ADLs). Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 11/01/21 revealed he had bowel and bladder incontinence. Its goal stated Resident #1 will be clean and odor free through the next review date. Observation of incontinence care for Resident #1 on 06/11/25 at 10:44p.m. revealed CNA A washed her hands prior to donning (putting on) gloves. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. 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 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 06/11/25 at 10:52 a.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 since July 2024 and received infection control training in March 2025. 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 nervous. Page 1 of 2 455931 455931 06/12/2025 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During interview on 06/12/25 at 4:20 p.m. the DON stated she was aware of some of the concerns raised about infection control practice. She stated she and ADON B was responsible for infection control in the facility. The DON stated employees received training on hire, every March and annually. She noted the regional nurse conducts spot checks and training with return demonstration periodically. The DON explained aides were expected to follow standard precaution including washing hands and changing gloves while providing care. Review of the facility's infection control policy revised 04/12/2023 reflected the following: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: . Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism. that could be transmitted during providing resident care services. b. Hand hygiene shall he performed in accordance with our facility's established hand hygiene. procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. e. Environmental cleaning and disinfection is performed routinely with high touch cleaning. procedures. f All staff have responsibilities related to report cleanliness issues in the facility to the Administrator/designee and housekeeping. 455931 Page 2 of 2