Health inspection·February 16, 2023

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 four (Resident #2, Resident #12, Resident #39, and Resident # 44) of 23 residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure CNA A changed her gloves after they became contaminated during incontinent care while assisting Resident #44 and Resident #39. 2. The facility failed to ensure CNA B changed her gloves after they became contaminated during incontinent care while assisting Resident #12. 3. The facility failed to ensure CNA C changed her gloves after they became contaminated during incontinent care while assisting Resident #12. 4. The facility failed to ensure CNA D changed her gloves after they became contaminated during incontinent care while assisting Resident #2. 5. The facility failed to ensure CNA E changed her gloves after they became contaminated during incontinent care while assisting Resident #2. These failures could place residents' risk for cross contamination and the spread of infection. Finding include: Record review of Resident #2's admission record dated 02/16/2023 indicated she was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy (a condition marked by impaired muscle coordination and paralysis), reduced mobility, general muscle weakness, muscle wasting and atrophy (the thinning or loss of muscle tissue), dementia (a condition characterized by persistent loss of intellectual functioning with impairment of memory and abstract thinking), incontinence without sensory awareness (lack of voluntary control over urination or defecation), intellectual disabilities and anxiety disorders. She was [AGE] years of age. Record review of Resident #2's MDS assessment dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3.Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #2's care plan dated 01/11/23 indicated in part: Problem: Resident has potential for impairment to skin integrity related to incontinence. Goal: Resident will have no Page 1 of 4 675326 675326 02/16/2023 Central Texas Nursing & Rehabilitation 1800 N Broadway St Ballinger, TX 76821

F 0880 complications related to skin integrity. Interventions/tasks: Provide peri care after each incontinent episode. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #12's admission record dated 02/16/2023 indicated she was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (progressive disease involving damage to nerve cells in the brain and spinal cord causing numbness impairment of speech muscular coordination), muscle wasting and atrophy (the thinning or loss of muscle tissue), dysphagia (the impairment in the production of speech), morbid obesity. She was [AGE] years of age. Residents Affected - Some Record review of Resident #12's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3.Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #12's care plan dated 01/30/23 indicated in part: Problem: Resident has bladder incontinence related to physical limitations. Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Interventions/tasks: Change brief every 2 hours, wash, rinse, and dry perineum after incontinent episode. Problem: Resident has bowel incontinence related to physical limitations. Goal: Resident will remain free of complications related to bowel incontinence. Interventions/tasks: Change brief every 2 hours and provide peri care after every incontinent episode. Record review of Resident #39's admission record dated 02/16/2023 indicated he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia affecting right side (paralysis on right side of body), muscle weakness, dysphagia (the impairment in the production of speech), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). He was [AGE] years of age. Record review of Resident #39's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3.Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #39's care plan dated 11/24/22 indicated in part: Problem: Resident has bowel and bladder incontinence related to lack of perception and mobility. Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Interventions/tasks: Incontinent care at least every 2 hours and PRN and after each incontinent episode. Record review of Resident #44's admission record dated 02/16/2023 indicated she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (mental condition characterized by persistently depressed mood), Abnormality of gait and mobility, dementia (a condition characterized by persistent loss of intellectual functioning with impairment of memory and abstract thinking), dysphagia (the impairment in the production of speech). She was [AGE] years of age. Record review of Resident #44's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3.Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #44's care plan dated 01/16/23 indicated in part: Problem: Resident has ADL selfcare performance deficit. Goal: Resident will improve level of function for toileting. Interventions/tasks: provide assistance after toileting. During an observation on 02/14/23 at 10:30 AM CNA A performed incontinent care for Resident #39. CNA A entered the resident's room and did not wash her hands but donned clean gloves. Resident #39 was 675326 Page 2 of 4 675326 02/16/2023 Central Texas Nursing & Rehabilitation 1800 N Broadway St Ballinger, TX 76821

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some laying in his bed awake and alert. CNA A explained she would be performing incontinent care and closed the door and pulled the curtain. CNA A pulled down the front of the brief and wiped the peri area with wipes from clean to dirty. CNA A tucked the soiled brief in on itself and under the resident. Resident rolled himself to the left side, CNA A took some wet wipes and wiped the resident's bottom from clean to dirty. CNA A removed the soiled brief and threw it in the trashcan, then proceeded to place a clean brief under the resident. Resident rolled himself to his back. CNA A adjusted and secured the brief, while still wearing the same gloves. CNA A then doffed gloves but failed to wash hands. During an observation on 02/15/23 at 4:55PM CNA A performed incontinent care for Resident #44. CNA A entered resident #44's room and did not wash her hands but donned clean gloves. Resident #44 was in bed, awake with eyes closed. CNA A explained that she would be performing incontinent care and closed the door and pulled the curtain. Resident rolled herself to her back and CNA A pulled down the front of the soiled brief and wiped the peri area with wipes from clean to dirty and tucked the brief in on itself and tucked under resident. Resident rolled herself to her left side and CNA A wiped her bottom with wet wipe and folded it in half and wiped her again. CNA A then removed soiled brief and placed clean brief under resident. Resident rolled herself to her back and CNA A secured the brief. CNA A then pulled the residents pants on with the same gloves. CNA A then doffed gloves and covered resident with her blanket. During an observation on 02/16/23 at 9:19AM CNA B performed incontinent care for Resident #12. CNA B and CNA C entered resident #12's room and explained that they would be performing incontinent care and washed their hands in residents' restroom. The CNA's set up their supplies and a change of clothing for the resident. CNA B pulled the front of the brief down and tucked it under resident, then proceeded to wipe the residents' peri area from clean to dirty. CNA B doffed her dirty gloves but failed to wash hands. CNA C assisted resident to roll to her left side and wiped the residents' peri area from clean to dirty and removed the soiled brief. CNA C doffed her soiled gloves but did not wash her hands and placed a clean brief under the resident with her bare hands. CNA C then donned clean gloves and assisted the resident to roll to her right side and adjusted the brief. CNA B donned clean gloves and applied barrier cream to the residents' peri area and secured the brief. Both CNA's doffed their soiled gloves but failed to wash their hands and dressed the resident with their bare hands. During an observation on 02/16/23 at 9:35AM CNA D performed incontinent care for Resident #2. CNA D and CNA E entered Resident #2's room and explained that they would be performing incontinent care and donned gloves, failing to wash their hands prior. CNA D pulled the resident's pants down, then pulled the soiled brief off completely. CNA D wiped the residents peri area, then CNA E turned the resident to left side. CNA D wiped residents bottom with wipes and placed clean brief under resident. CNA E rolled resident to her back and left bedside with soiled gloves, to retrieve clothes from closet. CNA D donned clean gloves, failing to wash her hands and dresses resident. During an interview on 02/16/23 at 10:35 AM Surveyor asked CNA D to describe the steps of incontinent care. CNA D described the entire process of incontinent care but failed to mention hand washing, hand sanitizing or changing of gloves. When prompted by the surveyor to include hand washing and hand sanitizing, CNA D stated that she forgot to wash her hands prior to starting incontinent care on Resident #2. CNA D then stated that she was unsure how many times she should be changing her gloves. 675326 Page 3 of 4 675326 02/16/2023 Central Texas Nursing & Rehabilitation 1800 N Broadway St Ballinger, TX 76821

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/16/23 at 10:45 AM Surveyor asked CNA E to describe the steps of incontinent care. CNA E described the process of incontinent care correctly. When asked why she did not wash her hand during resident #2's incontinent care, CNA E stated that she washed her hands prior to entering resident's room. CNA E stated that she forgot to use hand sanitizer after doffing gloves because she did not have any with her. CNA E stated that she usually carries hand sanitizer with her and stated that she was aware of the facilities policy. During an interview on 02/16/23 at 11:00 AM with CNA B and CNA C, CNA C stated that they were sometimes rushed to do cares and steps get skipped. She stated that she knew better, she was aware of the risk of infection to the residents when handwashing was skipped. CNA B stated that she did not have any hand sanitizer and there was none readily available in the room. CNA B stated that she will do better moving forward. During an interview on 02/16/23 at 11:15 AM, the DON was made aware of the observations of incontinent care performed by CNA A, CNA B (agency), CNA C (agency), CNA D (agency) and CNA E. He stated that all CNAs received training on CNA duties in CNA school and his expectations are that they should be proficient in those skills. DON stated that he expects CNA's to know proper hand washing and proper incontinent care practices. He stated that they are basic skills that all healthcare staff should know how to do. The DON stated that all facility staff gets in-services routinely, but he is unsure what training agency staff gets. Record review of the facility's policy titled Perineal Care and dated 5/11/2022 indicated in part: The purpose of this procedure aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the residents skin condition. Preparation: perform hand hygiene, don gloves, gently perform perennial care wiping from clean to dirty to avoid contaminating the urethral area. Female: working from front to back, wipe one side of the labia majora, continue perennial care to the inner thigh. Then wipe the other side. Use a clean pre moistened cleansing wipe for each stroke. Male: pull back the foreskin on uncircumcised males. Hold penis by the shaft wash in the circular motion from tip down to base, continue perennial care to the scrotum and inner thigh. Reposition foreskin of uncircumcised males. Use pre moistened cleansing wipe for each stroke. Reposition the resident to the side and gently perform care to the buttocks and anal area working from front to back without contaminating the perennial area. Note skin changes and apply moisture barrier cream as directed. Doff gloves and perform hand hygiene. 675326 Page 4 of 4