Health inspection·July 3, 2025

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 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 6 residents (Resident #1) reviewed for infection control.CNA A failed to properly dispose of Resident #1's soiled brief after incontinent are. CNA A failed to change gloves and perform hand hygiene after handling soiled brief.This failure could place residents at risk for infection and hospitalization. Residents Affected - Few Findings include: Record review of Resident #1’s, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, severe, with psychotic disturbance and agitation, muscle weakness, major depressive disorder (is a mental health condition that significantly affects how you feel, think, and behave). Record review of Resident #1’s quarterly MDS assessment, dated 06/17/2025, reflected a BIMS score of 7, which indicated severe cognitive impairment. It reflected he required maximum assistance with toileting hygiene. Record review of Resident #1’s care plan, initiated 01/03/2025, reflected the following: [Resident #1] has ADL Self Care Performance Deficit relating to dementia, impaired balance and limited mobility. Interventions included: The resident requires extensive assistance by 1 staff for toileting. Observation on 07/03/2025 at 11:23 AM, revealed CNA A walked with Resident #1 with gloved hands. CNA A turned around after the State Surveyors passed her and hurriedly ran to pick up a soiled brief that was left on the floor on the hall. CNA A used gloved hands, picked up the soiled brief and put in the barrel that was about 3 feet away. CNA A then went back to continue walking Resident #1 with the same gloved hands. During an interview on 07/03/2025 at 12:27 PM, CNA A stated when she was seen on the hall, she had just changed Resident #1’s soiled brief and was trying to get Resident #1 back to the day room quickly so she put the soiled brief on the floor to get back to it. CNA A stated she knew she was not supposed to put the soiled brief on the floor because it was not sanitary, she should have put the soiled brief in a bag and transported it to the barrel. CNA A stated she was not supposed to wear gloves while walking down the hall, but usually wore gloves to hold residents’ hands. CNA A stated holding Resident #1 with the same soiled gloved hands could cause infection. CNA A stated, Page 1 of 4 676026 676026 07/03/2025 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 “I was in a rush, I messed up.” Level of Harm - Minimal harm or potential for actual harm During an interview on 07/03/2025 at 1:19 PM, the Infection Control Preventionist stated soiled briefs were supposed to be placed in a bag and the bag placed in the soiled brief barrel in a room on each hall. The Infection Control Preventionist stated it was not okay to put soiled briefs on the floor, because it could spread germs (microorganism that causes disease) . The Infection Control Preventionist stated it was not okay to walk around with gloves on, because they did not know where those gloves came from. The Infection Control Preventionist stated staff were educated to take the gloves off after care and while on the halls. The Infection Control Preventionist stated it was not okay to touch the resident with a soiled gloved hand, because it could spread of germs, the resident might touch their eyes, and their eye could get infected. Residents Affected - Few During an interview on 07/03/2025 at 2:53 PM, the DON stated it was not okay to put the soiled brief on the floor due to infection control. The DON stated CNA A was not supposed to walk around with gloves on while in the hall. The DON stated if CNA A touched the soiled brief, CNA A was supposed to remove the soiled gloves, wash her hands before touching Resident #1. Record review of the facility's policy titled Infection Briefs/Underpads, revised January 2024, reflected: “Purpose The purpose of this procedure is to provide guidelines for changing a soiled brief and underpad… 13. Remove underpad from resident by rolling the underpad toward the inside soiled area. Place the underpad in the nearby receptacle/container. Steps in the Procedure 14. Remove gloves, sanitize hands and replace with clean gloves… 19. Discard disposable equipment and supplies in designated containers. 20. Remove gloves and perform hand hygiene.” Record review of the facility's policy titled infection Standard Precautions, revised September 2022, reflected: “Policy Statement Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation 676026 Page 2 of 4 676026 07/03/2025 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 Level of Harm - Minimal harm or potential for actual harm 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situation. Residents Affected - Few Standard precautions include the following practices: 1. Hand Hygiene b. Hand hygiene is performed with ABHR or soap and water: (1) before and after contact with the resident. (4) after contact with items in the resident's room; and (5) after removing gloves. 2. Gloves Gloves are not to be reused. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.” Record review of the facility's policy titled Handwashing / Hand Hygiene, revised October 2023, reflected: Policy: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitor. Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident. 676026 Page 3 of 4 676026 07/03/2025 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); Level of Harm - Minimal harm or potential for actual harm c. after contact with blood, body fluids, or contaminated surfaces. Residents Affected - Few d. after touching a resident. e. after touching the resident's environment. f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.” 676026 Page 4 of 4