Health inspection·October 4, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 9 (Resident #1) residents observed for dignity in that: -The facility failed to have a privacy curtain in Resident #1's room during wound dressing change. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem. Findings: Record review of Resident #1's face sheet revealed an 83year old male admitted to the NF on 04/25/2023 with the following diagnoses: acute cystitis (inflammation of the bladder) without hematuria (blood in urine), obesity, hypertension (high blood pressure), atherosclerosis (build up cholesterol/fat in the artery causing obstruction of blood), coronary artery bypass, pneumonia (infection in the lung), gastro-esophageal reflux disease (acid from the stomach that backs up in the throat), and low back pain. Record review of Resident #1's MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating cognition level intact. Further review revealed that resident required extensive assistance with bed mobility, dressing, and toileting. Further review revealed that Resident #1 had 1 unhealed pressure ulcer. Record review of Resident #'s Physician Orders -dated 04/26/2023, indicated Venelex external ointment (alsam [NAME]-castor oil) apply to sacrum topically everyday shift for wound healing cleanse stage 2 to sacrum with NS (normal saline) or WC (wound cleanser). Pat dry, apply venelex and cover with a foam dressing. Change daily and PRN soiling. Record review of Resident #1's Care Plan dated 04/26/2023 revealed that resident was being care planned for stage 2 pressure ulcer of the sacrum. Observation on 05/06/2023 at 1:03p.m. Resident #1 was resting in bed on a regular mattress. Resident #1 was alert and oriented wearing oxygen via nasal cannula. Resident #1 bed was by the door. Resident #1's roommate was resting quietly in bed with eyes closed. LVN A entered room with dressing change supplies. Further observation was made of Resident #1 not having a privacy curtain. LVN A proceeded to change Resident #1's dressing to the sacral region with the assistance of CNA B. Both LVN A and CNA B repositioned Resident #1 in bed and began to change resident soiled linen on his bed. Page 1 of 4 675323 675323 10/04/2023 Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 was wearing a brief. LVN A removed the old dressing to Resident #1's sacral wound. LVN A began to clean the sacral wound bed that was observed with redness but no drainage. LVN A cleanse the wound bed with normal saline and proceeded to pat dry the wound bed and then applied ointment followed with a border dressing. Interview on 05/06/2023 at 1:10p.m. LVN A said the privacy curtain needed to be pulled to provide privacy as well as dignity for the resident. LVN A said when she worked last week the privacy curtain was there and asked what was she supposed to have done after seeing that resident did not have a privacy curtain, stop, and get another privacy curtain before changing resident dressing? Interview on 05/06/2023 at 2:00p.m. the Administrator said Resident #1 privacy curtain was washed on last week and had not been hung back up in Resident #1's room. The Administrator said he could not say why the privacy curtain was not hung. Interview on 05/06/2023 at 2:05p.m. the Maintenance Director said he was not aware that Resident #1 did not have a privacy curtain in his room. The Maintenance Director said the only explanation he had for the surveyor was that housekeeping took the privacy curtain down to wash it. The Maintenance Director said he would reach out to one of the staff members in his department to take care of the situation. Record review of the NF Policy on Dignity revise February 2021 revealed in part: .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always treated with dignity and respect .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . 675323 Page 2 of 4 675323 10/04/2023 Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573

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 help prevent the development and transmission of communicable disease and infections for 1 of 9 (Resident #1) residents reviewed for infection control in that: Residents Affected - Few -LVN A failed to practice infection control when changing Resident #1's dressing to the sacrum. This failure placed resident at risk for cross contamination and spread of infections and hospitalization. Findings : Record review of Resident #1's face sheet revealed an 83year old male admitted to the NF on 04/25/2023 with the following diagnoses: acute cystitis (inflammation of the bladder) without hematuria (blood in urine), obesity, hypertension (high blood pressure), atherosclerosis (build up cholesterol/fat in the artery causing obstruction of blood), coronary artery bypass, pneumonia (infection in the lung), gastro-esophageal reflux disease (acid from the stomach that backs up in the throat), and low back pain. Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 13 indicating cognition level intact. Further review revealed that resident required extensive assistance with bed mobility, dressing, and toileting. Further review revealed that Resident #1 had 1 unhealed pressure ulcer. Record review of Resident #'s Physician Orders revealed as follows: -dated 04/26/2023, indicated Venelex external ointment (alsam [NAME]-castor oil) apply to sacrum topically everyday shift for wound healing cleanse stage 2 to sacrum with NS (normal saline) or WC (wound cleanser). Pat dry, apply venelex and cover with a foam dressing. Change daily and PRN soiling. Record review of Resident #1's TAR for May 2023 revealed that the NF was changing dressing as order by the physician. Record review of Resident #1's Care Plan dated 04/26/2023 revealed that resident was being care planned for stage 2 pressure ulcer of the sacrum. Observation on 05/06/2023 at 1:03p.m. Resident #1 resting in bed on a regular mattress. Resident #1 was alert and oriented wearing oxygen via nasal cannula. Resident said it was okay for the surveyor to observe dressing change to his sacrum. LVN A entered Resident #1's room with gloves on and wound supplies in her hand. LVN A placed the dressing change supplies on resident bedside table without sanitizing her workspace and began to assist the CNA B with repositioning resident in bed and changing resident soiled linen on his bed. After assisting CNA B, LVN A began to wipe down resident mattress with a disposable wipe. LVN A then removed gloves and put on a new set of clean gloves not washing her hands and began to remove Resident #1's old dressing to his sacrum. LVN A began to clean the sacral wound bed that was observed to be red in color with no drainage. LVN A clean the wound bed with normal saline one wipe at a time disposing of all soiled materials inside of a brown box line with a clear plastic bag. LVN A proceeded to pat dry the wound bed then applied ointment to the wound bed 675323 Page 3 of 4 675323 10/04/2023 Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few followed with a border dressing. When LVN A was done changing Resident #1's wound to the sacrum, LVN A instead of removing gloves and washing her hands began to touch Resident #1's personal items on resident bedside table. LVN A then removed her gloves and went to the bathroom to wash her hands. Interview on 05/06/2023 at 1:10p.m. LVN A said she had on her gloves when she entered the room because she was carrying resident supplies. LVN A said should have done the following: sanitize her workspace before changing Resident #1's dressing to his sacrum, washed her hands, changed her gloves during dressing change going from dirty to clean as well as placing soiled material inside of a red biohazard bag to prevent cross contamination for infection control purposes. LVN A said she was taught to perform these steps when doing a dressing change to prevent the spread of infections. LVN A said she must have gotten nervous. Record review of the NF Policy on Hand washing/Hand Hygiene revised December 2006 revealed in part: .This facility considers handwashing/hand hygiene as the primary means to prevent the spread of infection . 675323 Page 4 of 4