Health inspection·October 31, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 3 residents (Resident #1) reviewed for accident hazards in that: CNA D did not ensure Resident #1's bed was locked after providing care. This failure could place dependent residents at risk for falls, injuries and decreased quality of life. Findings included: 1.Record review of the face sheet dated 10/31/23 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including, arteriovenous malformation of digestive system vessel ( a tangle of blood vessels that irregularly connects arteries and veins) vascular dementia, muscle weakness, unspecified abnormalities of gait and mobility, high blood pressure, type 2 diabetes, heart disease, and history of urinary tract infection. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated she required extensive assistance with bed mobility, locomotion in her wheelchair on the unit, dressing, toilet use and personal hygiene. The MDS indicated she was totally dependent on staff for transfers, locomotion off the unit in her wheelchair and bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. Record review of the care plan dated 8/17/23 indicated Resident #1 was at risk for falls, the care plan interventions included anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance. The care plan indicated Resident #1 had a history of hip fracture after a fall that was surgically repaired. The care plan interventions included, . modify environment as needed to meet current needs: Non-slip surface for bath/shower, bed in the lowest position with wheels locked . During an observation and interview on 10/31/23 at 11:20 a.m., CNA B and CNA D provided incontinent care to Resident #1. After the care was provided CNA B left the room. CNA D remained in the room. CNA D moved the bed back against the wall to its original position then went to wash her hands. The bed lock was not engaged. Taking a bag of clean linen CNA D started to exit the room. The surveyor asked CNA D to come back into the room and check the bed brake. CNA D said she forgot all about the Page 1 of 6 675664 675664 10/31/2023 Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482

F 0689 brake and then locked the bed brake. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/31/23 at 11:35a.m., CNA B said it was very important to ensure the beds were locked after care was provided because the resident could move/ cause the bed to roll, and they (the resident) could fall out of the bad. Residents Affected - Few During an interview on 10/31/23 at 11:36 a.m., CNA D said it was important to ensure bed brakes were locked after providing care. CNA D said she just completely forgot to check that the bed brakes were locked. CNA D said it was important to ensure bed brakes were locked to prevent the resident from falling. During an interview on 10/31/23 at 12:47 p.m., LVN A said she expected CNAs to ensure bed wheels were locked after providing care. LVN A said they frequently had to unlock the bed and move from the wall to provide incontinent care. LVN A said CNAs should ensure the brakes were locked after administering care because a resident could become injured if the resident fell out of the bed. During an interview on 10/31/23 at 3:10 p.m., the DON said a number of things could happen if staff did not ensure bed brakes were engaged after care. The DON said ultimately the resident could fall out of the bed and become injured. The DON said if staff had to unlock and move a bed in order to provide care, he expected them to return the bed to its previous position and lock the bed brakes to prevent accidents . During an interview on 10/23/23 at 3:15 p.m., the Administrator said if staff had to unlock and move a bed in order to provide care, she expected them to return the bed to its previous position and lock the bed brakes to prevent accidents. Record review of the policy and procedure titled Fall Evaluation and Prevention, revised August 2020, stated Purpose: To ensure the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents . Intervention suggestions for fall prevention .Place the bed in the lowest position and lock wheels . 675664 Page 2 of 6 675664 10/31/2023 Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482

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 and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #1 and Resident #2) reviewed for infection control practices in that: Residents Affected - Some CNA B did not ensure Resident #1 was cleansed of stool when she (CNA B) performed incontinent care. CNA C did not ensure Resident #2 was cleansed of stool when she (CNA C) performed incontinent care. CNA C did not remove her dirty gloves, perform hand hygiene (wash her hands or use hand sanitizer) and place clean gloves on before grabbing Resident #2's draw sheet during incontinent care. These failures could place residents at risk for cross contamination and infections. Findings included: 1.Record review of the face sheet dated 10/31/23 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including, arteriovenous malformation of digestive system vessel ( a tangle of blood vessels that irregularly connects arteries and veins) vascular dementia, muscle weakness, unspecified abnormalities of gait and mobility, high blood pressure, type 2 diabetes, heart disease, and history of urinary tract infection. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated she required extensive assistance with bed mobility, locomotion in her wheelchair on the unit, dressing, toilet use and personal hygiene. The MDS indicated she was totally dependent on staff for transfers, locomotion off the unit in her wheelchair and bathing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. Record review of the care plan dated 8/17/23 indicated Resident #1 was incontinent of bladder the care plan interventions included check Resident #1 every 2 hours as needed for incontinence. Wash, rinse and dry perineum. The care plan also indicated Resident #1 had an ADL self-care deficit related to chronic pain and decreased mobility. The care plan interventions indicated Resident #1 required the assistance of two nursing staff for toileting. Record review of the nursing progress note dated 10/27/23 stated Resident #1 had completed ABT(antibiotic) for UTI (urinary tract infection) . During an interview on 10/30/23 at 2:20 p.m., Resident #1's visitor said the was concerned Resident #1 was being cleaned well during incontinent care because she (Resident #1) had multiple urinary tract infections over the past several months. During an observation on 10/31/23 at 11:20 a.m., CNA B and CNA D provided incontinent care to 675664 Page 3 of 6 675664 10/31/2023 Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1. During the incontinent care, CNA B cleansed the front pubic area and thighs of Resident #1. CNA did not separate the labia and cleanse the periurethral area (area/ tissue surrounding the urethra). CNA B and CNA D then rolled Resident #1 side to side cleaning the buttock and place a clean brief under Resident #1. There was no stool noted the to the buttock or the dirty brief. CNA B and CNA D then returned Resident #1 to the supine position (laid on her back) and started to secure the brief. Before they (CNA B and CNA D) secured the brief the surveyor asked they separate the labia and cleanse the peri-urethral area. CNA B and CNA D started to move the Resident #'1 legs in order to clean the area. Resident #1 communicated she had some discomfort and could not mover her left leg but could move her right leg with assistance. CNA B assisted Resident #1 with slight movement of the right leg, then separated the labia and with a clean wipe, wiped the periurethral area. There was visible stool on the wipe after CNA B wiped between the labia. CNA B wiped the periurethral area two additional times before the wipe had no visible stool. During an interview on 10/31/23 at 11:35a.m., CNA B said she did not realize there was stool in the periurethral area when she and CNA D had completed with the care for Resident #1. CNA B said she knew she should have separated the labia and cleansed the periurethral area of Resident #1. CNA B said she was trying to be gentle and not cause discomfort for Resident #1. CNA B said she should have ensured the periurethral was cleansed because stool in that area could quickly cause infections. CNA B said if Resident #1 complained of discomfort during or with the attempt of incontinent care the CNAs would report the situation to the charge nurse. During an interview on 10/31/23 at 11:36 a.m., CNA D said she did not realize there was stool in the periurethral area when she and CNA B had completed with the care for Resident #1. CNA D said it was important to ensure a resident's periurethral area was cleansed of stool in order to prevent infection. CNA D said if Resident #1 complained of discomfort during or with the attempt of incontinent care the CNAs would report the situation to the charge nurse. CNA D said maybe Resident #1 would have some pain medication available that would make providing the care easier. During an interview on 10/31/23 at 12:15 p.m., Resident #1 said her left leg had caused her discomfort since her hip fracture. Resident #1 said she could move her right leg, that it just hurt a little. Resident #1 said CNAs had not been separating her labia and wiping good she said they barely wiping the front. Resident #1 said she had not had a bowel movement since yesterday. During an interview on 10/31/23 at 12:47 p.m., LVN A said she had worked at the facility about a month and regularly took care of Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said during her time at the facility, no CNAs had come to here and reported they (CNAs) had difficulty or that Resident #1 complained of discomfort with incontinent care. LVN A said it was very important to ensure stool was removed from the periurethral area in order to prevent infections. 2. Record review of the face sheet dated 10/31/23 indicated Resident #2 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including, dementia, muscle wasting and atrophy (the wasting or thinning of muscle mass), history of cellulitis of the left lower limb, kidney cancer, and type 2 diabetes. Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and usually made herself understood. The MDS indicated Resident #2 had severe cognitive impairment (BIMS of 0). The MDS indicated Resident #2 had no behavior of rejecting care. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, toilet use, personal hygiene and was totally dependent on staff for bathing. The MDS indicated she was 675664 Page 4 of 6 675664 10/31/2023 Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482

F 0880 always incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm Record review of the care plan dated 9/12/23 indicated Resident #2 was incontinent of bowel. The care plan interventions included check Resident #2 every 2 hours and provide peri-care after each incontinent episode. The care plan also indicated Resident #2 had an ADL self-care deficit related to vision impairment and decreased mobility. The care plan interventions indicated Resident #2 required the extensive assistance of 1 nursing staff for toileting. Residents Affected - Some During an observation on 10/31/23 at 1:25 p.m., CNA C and CNA E provided incontinent care to Resident #2. ADON F stood in the room. CNA C cleansed the front pubic area, the periurethral area and thighs of Resident #2. CNA C and CNA E then turned Resident #2 on her right side to clean her buttock. CNA C wiped the surface of Resident #2's buttock, she did not separate and wipe the intergluteal cleft (the deep groove which runs between the two buttocks from just below the sacrum to the perineum). CNA C asked for another wipe and with it wiped the back of Resident #2's upper thighs. CNA C then announced ok. CNA C asked CNE E to hand her clean gloves. The surveyor asked CNA C to separate the intergluteal cleft and wipe Resident #2. C NA C then, with a clean wipe, wiped the intergluteal cleft. There was visible stool on the wipe after CNA C wiped the intergluteal cleft. CNA C wiped the area 2 additional times to ensure there was no stool. CNA C then without changing her gloves reached over the resident and grabbed the draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress to cover the area between the person's upper back and thighs, often used by medical professionals to move patients) and rolled the resident on her left side. During an interview on 10/31/23 at 1:30 p.m., CNA C said she forgot to change her gloves after wiping stool from Resident #2's intergluteal cleft and before she grabbed the draw sheet because she was nervous. CNA C said she did wipe Resident #2's intergluteal cleft at the Surveyor's request but was not done with the care. When asked why she announced ok and requested clean gloves she said, I was not done. During an interview on 10/31/23 at 1:32 p.m., CNA E said she could not see how CNA C had wiped Resident #1 during the incontinent care because she was standing on the other side. CNA E said it was important to ensure residents were cleansed of stool to prevent skin breakdown. CNA E said CNA C should have removed her dirty gloves, performed hand hygiene (washed her hands or use hand sanitizer), and put on new gloves before she grabbed the draw sheet. CNA E said it was important to ensure gloves were changed from clean to dirty to prevent cross-contamination. During an interview on 10/31/23 at 1:33 p.m., ADON F said she could not say if CNA C was done with the care when the surveyor requested Resident #2's intergluteal cleft be wiped. ADON F said I don't think she (CNA C) would have left her (Resident #2) that way. ADON F said CNA C should have removed her dirty gloves, performed hand hygiene (washed her hands or use hand sanitizer), and put on new gloves before she grabbed the draw sheet. ADON F said it was important to ensure gloves were changed from clean to dirty to prevent the spread of bacteria. ADON F said it was important to ensure stool was removed from residents during incontinent care to avoid skin breakdown and cross contamination. During an interview on 10/31/23 at 2:52 p.m., LVN G said staff should ensure stool was removed from a resident in the periurethral and intragluteal cleft when incontinent care was provided. LVN G said residual stool left in the periurethral area would definitely increase the likelihood of a urinary tract infection and residual stool within the intragluteal cleft could lead to skin breakdown. LVN G said staff should ensure they change their gloves, perform hand hygiene, and put new gloves before touching clean items (such as a resident's drawsheet). LVN G said staff could accidently cause 675664 Page 5 of 6 675664 10/31/2023 Sunny Springs Nursing & Rehab 1200 Jackson St N Sulphur Springs, TX 75482

F 0880 cross contamination by touching clean items with dirty gloves. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/3/23 at 3:10 p.m., the DON said he expected staff to ensure residents were cleansed of stool during incontinent care. The DON said it was important to ensure stool was removed from the periurethral area to prevent the migration of bacteria and prevent infection. He said it was important to ensure the stool was removed from all areas of the buttock to prevent skin breakdown and potential infection. The DON said he expected staff to remove dirty gloves after stool had been cleansed from a resident perform hand hygiene, and place new gloves on before touching any clean items (such as the draw sheet). The DON said touching clean items with dirty gloves was an infection control issue. The DON said the facility had just completed skills check offs which included incontinent care and all the CNAs had done well at that time. Residents Affected - Some During an interview on 10/23/23 at 3:15 p.m., the Administrator said she expected staff to ensure that residents were cleansed of stool during incontinent care to prevent skin breakdown and infections. The Administrator said she expected staff to ensure they changed their dirty gloves before touching any clean items (such as a resident's drawsheet). Record review of the facility policy and procedure titled Perineal Care, revised June of 2020, found the policy stated Purpose: to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown .(VI) Wash the pubic area. (a) For female residents: Separate the labia. Wash with soapy washcloth/cleansing wipe, moving front to back, on each side of the labia and in the center over the urethra and vaginal opening, using a clean washcloth/cleansing wipe for each stroke .(VIII) Wash, rinse and dry buttocks and peri-anal area with contaminating perineal area .(XII) Remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, side rails, clean linen, call bell, etc.) . 675664 Page 6 of 6