Health inspection·August 16, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #1) reviewed for incontinent care. -The facility failed to ensure CNA J properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 05 out of 15, which indicated she was severely impaired cognitively. The MDS revealed she was dependent on staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. Section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly Page 1 of 4 675046 675046 08/16/2024 Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made. Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care assisted by Wound Care Nurse. CNA J removed Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at this facility last month. CNA J said she did not spread Resident #1's labia and clean the resident's meatus during incontinent care because I changed her diaper before breakfast around 8am. She said the failure placed the resident at risk for infections. In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said CNAs were provided training and competency check offs upon hire, quarterly and as needed. No policy on peri care was provided on exit. Record review of facility's Nursing Peri-Care Performance Criteria revealed read in part: .FEMALE 10. Positions waterproof pad under buttocks. 11. Helps to flex knees and spread legs apart. Notes limitation in positioning. 12. Cleanses the upper thighs. 13. Separates labia minora to expose urethral meatus and maintains hand position while cleansing. 14. Cleanse in one direction from clean to dirty. 15. Cleanse each side of labia maiora. 16. Wipe in the direction from perineum to rectum. 17. Use a separate wipe for each stroke and discard. 18. Discard gloves , hand sanitize or wash hands and apply a clean set of disposable gloves. 19. Dries perinea! area thoroughly using a different section of the towel for each stroke. 20. Asks patient/resident to lower legs and assume side lying position. Assists as necessary. 675046 Page 2 of 4 675046 08/16/2024 Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471

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 review, 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 and infection for 1 of 2 residents (Resident #1) reviewed for infection control. Residents Affected - Few -The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed . Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made. Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting 675046 Page 3 of 4 675046 08/16/2024 Rosenberg Health & Rehabilitation Center 1419 Mahlman St Rosenberg, TX 77471

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves . Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure . 675046 Page 4 of 4