Health inspection·February 2, 2024

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 1 of 5 resident (Resident #1) reviewed for infection control, in that: Residents Affected - Few The facility failed to ensure the PTD was wearing the appropriate PPE while in Resident #1's room, who was in isolation. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings were: Record review of Resident #1's face sheet dated 02/02/2024 revealed an admission date of 01/12/2024 and diagnoses which included: Clostridium Difficile Colitis(inflammation of the colon caused by bacteria), Chronic Obstructive Pulmonary Disease ( a group of lung diseases that block airflow and make it difficult to breathe), Unspecified Atrial Fibrillation( the heart's upper chambers beat chaotically and irregularly), and Gastro-esophageal reflux ( a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #1's Annual MDS assessment, dated 01/17/2024, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, last reviewed 01/18/2024, revealed a Focus: The resident has + C.Difficile results. Date initiated 01/18/2024. Record review of Resident #1's Medical assessment dated [DATE] revealed the resident was on a CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Date Initiated: 01/18/2024 Observation on 02/01/2024 at 1:52 p.m. revealed Resident #1's hallway had Resident #1's room set up with 3-drawer cart outside of door, filled with masks, face shields, gowns, and gloves. Further Page 1 of 2 675815 675815 02/02/2024 Kingsville Nursing and Rehabilitation Center 3130 S Brahma Blvd Kingsville, TX 78363

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observation revealed there were trash bins for doffing face masks and shields, hand sanitizer and signs on the wall and doors regarding isolation precautions. Observation on 02/01/2024 at 1:52 p.m. revealed PTD present in Resident #1's room, who was in isolation, wearing only a surgical mask that was pulled down around PTD's chin. Further observation revealed PTD exiting the room and returning to the Physical Therapy room where other residents and staff were present. PTD touched residents call light on bedside table, while he helped her to raise the head part of the bed for Resident #1. In an interview with PTD and the DON on 02/01/2024 at 02:14 p.m., the PTD stated he was only going in their real quick to assist Resident #1 with her bed because she asked him for help. PTD acknowledged he had received infection control training and using PPE. The DON informed PTD that no matter the length of time that he was in an isolation room, any person must follow the orders that are on the wall on what to wear when entering a room with precautions. The DON further revealed all staff were trained on infection control and isolation precautions, knew the procedures and risk of spreading the infection to themselves and other residents. She stated PTD should have been aware of the PPE set up in the hall and would provide PTD with further in-service training immediately. Record review for an in-service training on infection control provided on 02/01/2024 was signed by PTD. Record review of the Infection Prevention and Control Program, updated May 13, 2023, provided by the DON as part of the facility Infection Control Procedures, revealed, a section Personal Protective Equipment; Health Care P rovider who enter the room of a patient with suspected or confirmed Clostridium Difficile Colitis infection should adhere to Standard Precautions). Record review of the facility's policy titled, Infection Control Plan: Overview, updated 05/2023, revealed, Preventing Spread of Infection: The facility will require staff to Donn and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility. 675815 Page 2 of 2