Health inspection·February 27, 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 diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Residents Affected - Few CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care to Resident #1 on 02/25/2025. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #1's face sheet dated 02/27/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Covid-19, gangrene (death of body tissue due to lack of blood flow or infection), acquired absence of right leg above knee (amputation), acquired absence of left leg above knee (amputation), and muscle weakness. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required substantial/maximal with most activities of daily living (ADLs) and always incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 03/15/24 revealed he has bowel and bladder incontinence. The goal was for the resident to remain free of skin breakdown due to incontinence and brief use through the review date. Observation on 02/25/25 at 3:30 p.m. of incontinence care on Resident #1 revealed CNA A and CNA B washed their hands before donning gloves. Resident #1's brief was completely soiled with fecal matter. CNA A and CNA B removed Resident #1's soiled brief. CNA A wiped the resident from front to back. The wipes were visibly soiled with fecal matter, but she continued to use it. She did not wash hands, change gloves, or perform any form of hand hygiene before then applying skin protector on Resident #1. CNA A then retrieved the clean brief with same soiled gloves and fastened it to Resident #1. CNA A used the same soiled gloves throughout the incontinent care process. Meanwhile, CNA B who was assisting CNA A wiped the Resident #1's back perineal side after repositioning. She did not change gloves before helping to fasten the clean brief. CNA A picked up the trash and walked out of the resident room without washing hands. CNA B completed incontinence care and washed her hands before exiting Resident #1's room. Page 1 of 2 675145 675145 02/27/2025 Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/25/25 at 3:41 p.m., CNA A said she had been employed in the facility for 3 months and received infection control training during orientation. CNA A stated cross contamination was combining clean with dirty. CNA A stated she should have changed gloves before applying skin protector, picking up the clean brief and fastening it on Resident #1. She added Resident #1 could get an infection for not following good infection control practice. She added she was nervous and that was reason for not following good infection practice. During interview on 02/25/25 at 3:37 p.m., CNA B revealed cross contamination was going from clean to dirty. She acknowledged she should have changed gloves before fastening Resident #1's clean brief. CNA B stated he had been employed 6 months in the facility and received infection control training 2 months ago. CNA B said Resident #1 could get sick for not changing her gloves. In an interview on 02/27/25 at 11:52 p.m. the DON acknowledged being aware of some of the concerns raised about infection control practice. She explained she and ADON D was responsible for infection control in the facility. They trained and monitored the staffs by watching them do it. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. The facility infection control plan updated 03/2022 reflected, The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. The facility perineal care policy dated 04/22/2022 stated the following important points: 1) If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care. 2) Do not wipe more than once with the same surface. 3) Doffing and discarding of gloves are required if visibly soiled. 4) Always perform hand hygiene before and after glove use 5) Do not discard pre-moistened cleansing wipes in the toilet unless they are marked flushable. 675145 Page 2 of 2