Health inspection·August 3, 2023

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 observation, interview, and record review the facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections for 1 (R#1) of 4 residents reviewed for urinary catheters, in that: CNA A did not ensure R#1's indwelling catheter tubing, was allowed to flow freely via gravity drainage and maintain position below the level of bladder, as indicated in R#1's care plan. These failures could place residents with indwelling urinary catheters at risk of infection. The findings include: Record review of R#1's Face Sheet dated 08/03/2023, admitted [DATE], documented a [AGE] year-old female with the following diagnoses of: Dementia (loss of cognitive functioning-thinking, remembering, and reasoning), Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis), acute kidney failure, and hypertension (high blood pressure). Record review of R #1's MDS assessment dated [DATE], documented a 6/10 BIMS score documenting a severe cognitive impairment. R#1 was coded to have an indwelling catheter. R#1 also required extensive assistance to total dependence of staff to assist in activities of daily living. Record review of R #1's Comprehensive Care Plan date initiated 07/02/2023 stated, Problem: R#1 has foley catheter infection UTI. Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions: CATHETER: The resident has 16 french/10cc size. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks throughout each shift. Monitor/document for pain/discomfort due to catheter. During an observation on 08/02/2023 at 2:17 PM, CNA A was granted consent from R#1 to perform catheter care. CNA A washed her hands, applied clean gloves, and removed the foley catheter drainage bag from the metal bed frame. CNA A placed the drainage bag on top of blankets located on top of the bed, that were positioned higher than the level of the bladder throughout catheter care. Urine was observed to back flow from the tubing into the bladder throughout catheter care. CNA A completed catheter care and washed her hands. During an interview on 08/02/23 at 01:47 PM, CNA A stated her reason for leaving the drainage bag on the bed was to avoid dislodgement of the catheter from the insertion area. CNA A stated she did Page 1 of 4 675309 675309 08/03/2023 Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not realize she positioned the drainage bag on the bed above the level of R#1's bladder. CNA A said due to the urine drainage bag being positioned above the level of R#1's bladder, potential reintroduction of contaminants could have led to infection. CNA A then stated she was nervous and does recall that the catheter drainage bag should not have been positioned on the bed. CNA A stated she does not recall any education or competencies given upon hire nor during employment regarding perineal/foley catheter care but does recall attending skills check off over the weekend of July 28th-30th. During an interview on 08/02/2023 at 4:04PM the DON and RN A both stated that foley catheters must be positioned below the bladder to prevent urine from reentering the bladder, which could potentially be detrimental to a resident's safety. The DON and RN A stated that re-entry of urine could lead to potential infection of excreted microorganisms. The DON and RN A stated the drainage bag should definitively not be positioned on the bed and must remain below the level of the bladder to minimize the chance of potential infection. The DON and RN A stated the ADONs conducted skills check off for CNAs on July 28th thru July 30th, and CNA A was in attendance. Both the DON and RN A stated that all CNAs were to demonstrate on mannequins, the proper technique regarding perineal/catheter care, and CNA A was given a completed passing performance. Both the DON and RN A stated check offs are conducted by ADONs monthly, annually, and as needed. Record review of facility's Indwelling urinary catheter (Foley) care and management undated stated, keep the drainage bag below the level of the patient's bladder but off the floor. Record review of the CDC Recommendations entitled Proper Techniques for Urinary Catheter Maintenance review date November 5, 2015, stated, B. Maintain unobstructed urine flow 1. Keep the catheter and collecting tube free from kinking 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 675309 Page 2 of 4 675309 08/03/2023 Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332

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, record review, and interview, 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 infections, for 1 of the residents (R# 1) of 5 that were reviewed for infection control and transmission-based precautions policies and practices, in that: Residents Affected - Few CNA A touched multiple surfaces and did not perform hand hygiene nor change contaminated gloves prior to performing catheter care for R#1. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R#1's Face Sheet dated 08/03/2023, admitted [DATE], documented a [AGE] year-old female with the following diagnoses of: Dementia (loss of cognitive functioning-thinking, remembering, and reasoning), Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis), acute kidney failure, and hypertension (high blood pressure). Record review of R #1's MDS assessment dated [DATE], documented a 6/10 BIMS score documenting a severe cognitive impairment. R#1 was coded to have an indwelling catheter. R#1 also required extensive assistance to total dependence of staff to assist in activities of daily living. Record review of R #1's Comprehensive Care Plan date initiated 07/02/2023 stated, Problem: R#1 has foley catheter infection UTI. Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions: CATHETER: The resident has 16 french/10cc size. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks throughout each shift. Monitor/document for pain/discomfort due to catheter. During an observation on 08/02/2023 at 2:17PM, CNA A knocked and entered R #1's room and was granted permission by R#1 to perform catheter care. Observed CNA A applied clean gloves followed by removal of R#1's blanket, pants, and soiled brief. Then CNA A proceeded to touch the metal bed frame to remove the foley catheter from the frame. CNA A, with the same initial gloves, placed left hand by the labial area, then with right hand took wipes and cleaned inside the perineum and catheter. After cleaning the perineal area, CNA A turned R#1 to the left side, removed contaminated gloves, performed hand hygiene, and applied new gloves followed by cleaning bowel movement. During an interview on 08/02/2023 at 2:33PM CNA A stated the objects and surfaces she touched prior to catheter care, could have been dirty, and contain infectious bacterial microorganisms. CNA A stated after touching the multiple surfaces, she should have removed her contaminated gloves, performed hand hygiene, and applied new clean gloves. CNA A stated she normally does perform glove changes and hand hygiene prior to catheter care but was nervous and it slipped her mind. CNA A stated she does not recall any in-services regarding catheter care but does recall attending skills check off over the weekend of July 28th-30th. 675309 Page 3 of 4 675309 08/03/2023 Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/02/2023 at 4:04PM, both the DON and RN A stated after CNA A touched the multiple surfaces, CNA A should have removed the contaminated gloves, performed hand hygiene, and applied new clean gloves. The DON and RN A stated CNA A potentially increased R#1's risk for contraction of infection and cross contamination, which could have led to adverse effects. Both the DON and RN A stated the facility held a skills lab the weekend of July 28th -30th, and CNA A was in attendance. Both the DON and RN A stated that all CNAs were to demonstrate on mannequins, the proper technique regarding perineal/catheter care, and CNA A was given a completed passing performance. Both the DON and RN A stated check offs are conducted by ADONs monthly, annually, and as needed. Record Review of the facility's Perineal Care Policy, dated 10/24/2022, stated: 6. Perform hand hygiene and put on gloves 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. 10. Change gloves if soiled and continue with perineal care Record Review of the Hand Hygiene Policy, dated 10/24/22, stated Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand hygiene prior to direct contact with resident, after removing gloves, after contact with blood or body fluids, after contact with a resident's skin, and before donning sterile gloves for procedures. Record Review of CNA Orientation Skills Check list dated 07/30/2023 did have CNA A in attendance. Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 8, 2021, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. 675309 Page 4 of 4