Health inspection·June 13, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **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 effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 1 of 28 residents (Resident #1) and 1 staff (SW) reviewed for infection control. Residents Affected - Some The SW failed to wear appropriate PPE and practice hand hygiene before entering or exiting room [ROOM NUMBER] for Resident #1 who was on contact isolation for Carbapenem Resistant Pseudomonas Aeruginosa (bacteria resistant to certain classes of antibiotics). The SW removed a reusable cup from room [ROOM NUMBER] and carried it to the community water station at the nurse's station, refilled the cup and returned the cup to room [ROOM NUMBER]. The SW entered three additional residents' rooms with signed posted enhanced barrier precaution after exiting room [ROOM NUMBER]. An Immediate Jeopardy was identified on 6/12/24/at 4:35 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:50 PM. While the immediate jeopardy was lifted on 6/13/24 at 4:15 PM, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. These failures could place residents at risk for infection and cross contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization, or death. Finding include: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female with an initial admission date of 10/06/2023 and a readmission date of 02/22/2024 with the following diagnoses: acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood), chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), tracheostomy status (surgically created hole in the windpipe for breathing), dependence on respirator [ventilator status], and hypothyroidism (thyroid condition). Record review of Resident #1's Quarterly MDS dated [DATE] revealed resident #1 had a BIMS of 08, which indicated the resident's cognitive status was moderately impaired. Additionally, section H - Bladder and Bowel revealed Resident #1 had an indwelling catheter, section M - Skin Conditions revealed Resident #1 had a pressure ulcer, and section O - Special Treatments, Procedures and Programs revealed Resident #1 received tracheostomy care and uses an invasive mechanical ventilator. Record Review of Resident #1's Care Plan, dated 02/22/2024, revealed Resident #1 was on contact Page 1 of 12 676028 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Immediate jeopardy to resident health or safety precautions related to Pseudomonas Aeruginosa in sputum (bacterial organism in lung secretions). Interventions were to have PPE readily outside of the resident's room, place sign in the resident's door to check with nurse prior to entering put gown, gloves, and to sanitize hands prior to entering and exiting the room. The Care Plan also revealed Resident #1 has Chronic Obstructive Pulmonary Disease (COPD), a tracheostomy related to respiratory failure, a Foley catheter, had oxygen therapy via trach collar secondary to respiratory failure, and was ventilator dependent related to respiratory failure. Residents Affected - Some Record Review of Resident #1's Physician's Orders dated 06/12/2024 revealed an order dated 02/23/2021 for isolation protocol for Carbapenem Resistant Pseudomonas Aeruginosa - Staff will require gown and gloves while giving care. The physician's orders further revealed an order dated 10/06/2023 for Trach care, an order dated 04/27/2024 for Foley catheter care, and an order dated 01/30/2024 for a vent setting: AC/VT = 450, Rate = 18, Peep = 8 8/liters every shift. Record Review of Resident #1's Discharge Instructions Record dated 02/22/2024 revealed CRPA infections can occur in a wound or surgical incision. It can also occur in other areas of the body, such as the urinary system, blood stream, lungs, and abdomen. CRPA infections may cause severe illnesses such as: Gastrointestinal illness, Pneumonia, bone or joint infections, bloodstream infections, and invasive infections in other body organs. CRPA bacteria may colonize wounds, the respiratory tract of some patients, and medical devices that are in place for a long time. Healthcare facilities may utilize isolation precautions to prevent the spread of the bacteria to other patients. The most effective way to prevent the spread of bacteria is to wash your hands often. This condition is caused by Pseudomonas aeruginosa bacteria that no longer responds to carbapenem antibiotic medicines. This bacterium can be spread by: direct contact of an open wound of an infected person, having contact with a medical device that has the bacteria on it (is contaminated), and touching surfaces or items that have been in contact with an infected person. Those most at risk include patients in hospitals, especially if: you had a long-term hospital stay, especially in an intensive care or burn unit, you have been on antibiotics for the treatment of other conditions, you use a breathing machine (ventilator), you use urinary (bladder) catheters, or are on kidney dialysis, you have a short-term or long-term vascular access device, such as a catheter or IV, you have wounds from surgery or burns, or you have a weakened defense system (immune system). Pseudomonas aeruginosa infections are generally treated with antibiotics. Unfortunately, people in exposed to healthcare settings like hospitals or nursing homes, Pseudomonas aeruginosa infections are becoming more difficult to treat because of increasing antibiotic resistance. To identify the best antibiotic to treat a specific infection, healthcare providers will send a specimen (often called a culture) to the laboratory and test any bacteria that grow against a set of antibiotics to determine which are active against the germ. The provider will then select an antibiotic based on the activity of the antibiotic and other factors, like potential side effects or interactions with other drugs. For some multidrug-resistant types of Pseudomonas Aeruginosa, treatment options might be limited. During an observation on 6/12/24 at 10:43 AM, the SW was observed in the 200 hall, entering room [ROOM NUMBER], which had a sign posted outside of the door for Contact Precautions, and a clear three drawer cart with PPE in the cart. The SW entered room [ROOM NUMBER] without any PPE on and did not practice hand hygiene. SW walked to the bedside near Resident #1 and spoke with Resident #1. SW picked up the re-useable drinking cup for Resident #1 and exited the room. SW walked down the hall to the nurse's station and used the community water station to refill the cup for Resident #1. SW touched the spout for the community water pitcher to refill the cup. SW placed the cup on the counter at the nurse's station and walked over to talk with another staff. SW walked back to the nurse's station and picked up the re-usable cup and walked back down the hall to room 676028 Page 2 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [ROOM NUMBER] and entered the room. SW placed the re-usable cup on the BST and exited the room. SW did not Donn (put on correctly)PPE either time she entered the room, and she did not practice hand hygiene any time she entered or exited the room. SW entered three additional resident rooms after exiting room [ROOM NUMBER]. SW entered room [ROOM NUMBER], 205 and 204. SW was observed knocking on the doors and pushing the doors open with her hands. There was signed posted on the outside of the door for room [ROOM NUMBER], 205 and 204 for Enhanced Barrier Precautions. The SW did not practice hand hygiene prior to entering or exiting rooms [ROOM NUMBER]. During an observation on 6/12/24 at 10:43 AM of a facility sign posted outside of room [ROOM NUMBER] titled Contact Precautions reflected (Contact Precautions are in addition to Standard Precautions. See Standard Precautions for questions) Attention! Visitors must report to the nurse station before entering. Patient Placement: Private room, if possible. Ensure that patients are physically separated (i.e.,>3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for direct contact. Personal Protective Equipment (PPE) Don gown and gloves outside of the resident's room. Remove gown and gloves and observe hand hygiene before leaving the patient-care environment. Hand Hygiene (according to Standard Precautions) Avoid unnecessary touching of surfaces in close proximity to the patient. When hands are visibly dirty, contaminated with proteinaceous material, visibly soiled with blood or body fluids, wash hands with soap and water. If hands are not visibly soiled, or after removing visible material with soap and water, decontaminate hands with alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Preform Hand Hygiene: Before having direct contact with patients After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure or lifting a patient) If hands will be moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient 676028 Page 3 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 After removing gloves Level of Harm - Immediate jeopardy to resident health or safety Patient Transport When transporting or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contaminated and covered. Residents Affected - Some Remove and dispose of contaminated PPE and preform hand hygiene before and after transporting patients on Contact Precautions. Patient-Care Equipment and Instruments/Devices If common use of equipment for multiple patient's is unavoidable, clean and disinfect such equipment before use on another patient. During an observation on 6/12/24 at 10:50 AM of facility sign posted outside of rooms 204, 205, 208 for Enhanced Barrier Precautions reflected: Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following: High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. During an interview on 6/12/24 at 10:54 AM, the SW stated she did not see the Contact Precaution sign posted outside the door for Resident #1 in room [ROOM NUMBER]. She stated she did not practice hand hygiene or Donn PPE before she entered room [ROOM NUMBER]. She stated she did not practice hand hygiene before she entered or exited rooms 208, 205 and 204. She stated the Enhanced Barrier Precaution sign posted outside of rooms [ROOM NUMBER] were posted so staff would know what to do when entering those rooms. She stated that Resident #1 had asked for more water, so she carried the re-usable cup down the hall to get more water and took it back. She stated that she had been trained and in-serviced on PPE and infection control and if the sign was posted staff should follow the instructions 676028 Page 4 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 posted. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 6/12/24 at 11:57 AM, the Corporate RN stated that if the sign was posted for Contact Isolation, then staff should observe the proper PPE prior to entering the room. She stated even if a staff entered the room to talk with the resident, they would need to observe the proper PPE per the sign posted. Residents Affected - Some During an interview on 6/12/24 at 2:35 PM, the DON stated the facility had trained and in-serviced staff over Infection Control, Enhanced Barrier Precaution, that the SW and other non-nursing staff would need additional education on infection control. She stated all staff should read the signs posted before they enter a room. She stated the SW should not have brought the re-usable cup out of the room, and the SW should get a foam cup and take the refill in the throw away cup in the room. The DON stated staff should not take personal belongings of a resident out of a room that is on isolation. She stated that SW did not follow the facility policy for contact precautions when she entered the room without PPE and took the resident's cup out of the room to refill it. She stated that SW placed other residents at risk for infection. During an interview on 6/13/24 at 11:52 AM, the Administrator stated the SW should have worn PPE and practiced hand hygiene before she entered Resident #1's room. She stated she expected staff to preform hand hygiene when they entered or exited a room, put on all needed PPE before they entered a room with contact isolation precaution, and equipment should be disposable. She stated the SW should not have carried the re-usable cup out of the room and down the hall to the community water station. She stated staff could have spread the bacteria to other residents, or staff. She stated that the DON would monitor staff and randomly pick staff to complete competency check offs on hand hygiene. She stated the DON had completed hand washing competency check offs and donning and doffing (take off correctly) PPE on all staff that had clocked in for work on 6/13/24. She stated the facility would discuss any area of concerns in the QA meeting. During an interview on 6/13/24 at 9:20 AM, the Corporate RN stated the facility knew they did not follow what was posted about contact isolation on 6/12/24. During an interview on 6/13/2024 at 1:31 PM with the NP whose office saw Resident #1, she stated she was familiar with Resident #1 as well as the resident's diagnosis of CRPA. She stated she was aware that Resident #1 was on contact precautions at the facility. The NP stated that in her professional opinion, a staff member removing a cup from the isolation room, carrying it down the hallway and using a community water station to refill it, then returning the cup to the isolation room, would place other residents on the hall at a huge risk for infection and/or cross contamination with CRPA. Record review of facility's resident roster for hall 200 dated 6/12/24 reflected 28 residents lived on that hall, 11 residents had active wounds, 12 residents received tube feeding, 22 residents had tracheostomies and 11 of those were ventilator dependent and 14 residents had catheters. Record review of facility provided policy titled, Fundamentals of Infection Control Precautions dated 2019, revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. 676028 Page 5 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Hand Hygiene Level of Harm - Immediate jeopardy to resident health or safety Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: o Before and after entering isolation precaution settings; Residents Affected - Some o After handling soiled equipment or utensils; Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. 5. Gowns and protective apparel 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment. Record review of facility provided policy titled, Transmission-based Precautions dated 2010, revealed: Transmission-based precautions are used for residents who are known to be, or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measures to prevent transmission. It is essential both to communicate transmission-based precautions to all health care personnel, and for personnel to comply with requirements. A sign will be placed at the resident's room entrance to See Nurse Before Entering so to communicate to staff and visitors so that the nurse can communicate any precautions; in addition, it will be communicated to staff via verbal report what type of precautions are required to care for the resident. It is important to use the standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precaution determines the type of PPE to be used. Communication (e.g., verbal reports, signage) regarding the particular type of precaution to be utilized is important. When transmission-based precautions are in place, PPE should be readily available. Proper hand washing remains a key preventive measure, regardless of the type of transmission-based precaution employed. Contact Precautions Contact transmission risk requires the use of contact precautions to prevent infections that are spread by person-to-person contact. Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room. Prior to leaving the contact precaution room the PPE is removed and hand hygiene is performed. Depending on the situation, options for residents on contact precautions may include the following: a private room, cohorting, or sharing a room with a roommate with limited risk factors (e.g., without indwelling devices, without pressure ulcers and not immunocompromised). 676028 Page 6 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Implementation of Transmission-Based Precautions Level of Harm - Immediate jeopardy to resident health or safety The Personal Protection Equipment (PPE) will be readily available near the entrance to the resident's room. Signage will be posted on the resident's door instructing visitors to see the nurse before entering. Record review of facility provided policy titled, Hand Washing dated 2012, revealed: Residents Affected - Some We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin. 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. c. Wet hands. d. Deliver soap in palm. e. Lather up soap. f. Cup the fingertips within the palms of the hands and rub vigorously. g. Interlock fingers and work them back and forth and side to side. h. Scrub back of hands, wrists and lower arms. i. Rinse hands, wrists, and lower arms thoroughly 3. Dry hands and arms with paper towel, then turn off the faucets with the paper towel. 4. Discard used paper towels in trash receptacle. 676028 Page 7 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 5. Level of Harm - Immediate jeopardy to resident health or safety Food preparation sinks are not to be used for hand washing. Residents Affected - Some This was determined to be an Immediate Jeopardy (IJ) on 06/12/2024 at 4:35PM. The Administrator, DON, and Corporate Nurse were notified. The Administrator was provided with the IJ Template on 06/12/2024 at 4:58 PM. The following Plan of Removal submitted by the facility was accepted on 06/13/2023 at 10:15 AM Record review of the facility Plan of Removal reflected the following: (Facility Name) Plan of Removal 06/12/2024

F880 ALLEGED ALLEGATION: Infection Control Staff did not wear correct PPE while entering the room of a resident on isolation Staff did not sanitize when entering and exiting the isolation resident room Staff removed a non-disposable beverage cup from the infected resident room and filled from the community water station and used hand to operate the spout. Staff placed infected resident cup on the nursing station contaminating the desk and placing immunocompromised residents at risk due to cross contamination. Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 6/12/2024: Any staff member not present or in-serviced on 6/12/2024, will not be allowed to assume their duties until in-serviced. o Staff will be Inservice on the following: In-service staff on Infection Control Overview In-service staff on proper PPE use for MDRO isolation and Enhanced Barrier Precautions In-service staff with return demonstration related to hand hygiene and donning and doffing PPE. In-service staff on management of multi- use or non-disposable items leaving isolation rooms In-service staff on Carbapenem-resistant pseudomonas aeruginosa (CRPA) 676028 Page 8 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 In-service staff over management of all dietary items including beverage cups using disposable items only. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some o Community water station was removed from service and sanitized prior to continued use. Nursing station was immediately sanitized to prevent cross contamination. o Disposable cups will be placed behind the nursing station for use with MDRO isolation residents. o All non-disposable cups were removed from the resident room. o Disposable blood pressure cuffs, thermometer, stethoscope to be kept in room to prevent cross contamination. o MDRO isolation signs will be printed in bright orange color to attract staff attention prior to entering resident rooms. The medical director was notified of the immediate jeopardy situation on 6/12/2024 at 1745. Monitoring The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts. The DON/designee will observe all MDRO resident rooms 3 times weekly to assure that non-disposable dietary items are not in resident room. The QA committee will review findings and makes changes as needed. During an observation on 6/13/24 at 10:25 AM revealed there was a bright orange contact precaution sign posted outside of room [ROOM NUMBER]. Staff observed donning PPE prior to entering the room. Disposable foam cups were observed in room [ROOM NUMBER]. The re-useable drinking cup was no longer in room [ROOM NUMBER]. During an observation on 6/13/24 at 10:30 AM revealed foam cups were at the nurse's station at the community water station for use. 676028 Page 9 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an observation on 6/13/24 at 11:24 AM revealed disposable equipment was observed in room [ROOM NUMBER] for staff use. Record review of the facility in-service dated 6/12/24 titled Meal Service to isolated residents revealed: Absolutely no trays may enter isolation residents' rooms. One staff member may don gown, mask, gloves and enter the resident room. A second staff member is to hand the disposable containers with resident meals to the staff member in PPE to give to resident. (76 staff had signed). Record review of the facility in-serviced dated 6/12/24 titled Transfer Devices with Isolation Residents revealed: Multi use, non-Disposable patient care devices must be sanitized upon completion of use. (i.e. Hoyer Lifts, Geri chairs). *K-Quat is to be used on non-disposable items. Other multi use patient care devices must remain in the resident's room and be sanitized upon completion of use. (i.e. BP cuff, stethoscope, pulse oximeter, glucometer). *Sani wipes to be used on these items. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Hand Hygiene and policy revealed: Hand Hygiene, you may use alcohol-based hand cleaner or soap / water for the following: and examples of when to use. You must use soap/water for the following (alcohol-based hand cleaner is not recommended) examples given. (77 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Enhanced Barrier Precautions and policy revealed: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled MDRO Isolation revealed: Carbapenem Resistant Pseudomonas aeruginosa/Carbapenem resistant Acinetobacter baumannii. Residents are on contact isolation. Disposable medical equipment is required (stethoscope, blood pressure cuff, pulse oximeter, etc.). disposable cups for hydration (water is carried into the room in disposable cups). Donning and doffing PPE is required (Gown, mask and gloves). Rooms are clearly marked with bright isolation signage. Any staff attempting to enter these rooms must perform hand hygiene, and don masks, gloves, gowns. Prior to exiting the room masks, gloves, gowns are removed and disposed of, and hand hygiene preformed. All staff are required to follow all infection control policies. (74 staff signed). Record review of the facility in-service dated 6/12/24 titled Refilling isolation beverages revealed: Residents on contact isolation are served meals on Styrofoam plates and disposable utensils to prevent cross contamination to the dietary department or staff picking up trays. When managing a non-disposable drinking cups for these residents, they may not leave the room to be refilled. We may bring in a disposable cup with ice and water to refill the container. Those are disposed of inside of the resident room. If the non-disposable drink receptacle needs to be washed, and cannot be washed in the room, we will throw it away and get a new one. (71 staff signed). Record review of competency test dated 6/13/24 and titled Putting on and Removing Personal Protective Equipment (PPE) revealed 45 tests were completed for staff. Record review of competency test dated 6/13/24 and titled Hand Hygiene revealed 48 tests were completed for staff. During an observation interview on 6/13/2024 at 11:24 AM with Resident #1 and family member who was present in the room, revealed the resident was connected to a ventilator via her tracheostomy and was able to answer questions with a head shake or nod. When asked if all staff donned 676028 Page 10 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some PPE prior to entering her room, Resident #1 nodded her head yes. When asked if staff were friendly with her while performing care, Resident #1 nodded her head yes. The family member also stated staff are very pleasant with the resident always. The family member stated prior to the foam cups being brought to the resident's room yesterday, the staff would bring drinks to the room in a disposable, clear cup. During an interview on 6/13/24 at 1:05 PM, the Dietary Aide stated she received in-serve on contact isolation precaution and the process that must be done before entering a resident room on those precautions. She stated she received in-service on EBP and when PPE would be needed. She stated there were signs posted outside the doors for EBP and bright orange signs posted for Contact precaution. She stated she was in-serviced on infection control and CRPA. She stated she was in-serviced on hand hygiene, and it must be performed prior to entering and exiting rooms; and how to preform hand hygiene, and staff completed competency check off for hand hygiene. She stated she was in-serviced on disposable containers used for residents on contact precautions, and that nothing could be removed from the room, as well as how a meal would be served, and that any items used that are not disposable must be cleaned and sanitized with K-quat sanitizer solution. She stated if she had any questions or concerns, she would ask staff before for assistance before she entered a room. During an interview on 6/13/24 at 1:36 PM, the MD Assistant stated the facility notified her of the IJ for infection control on 6/12/24 and the POR. She stated she informed the Medical Director and they agreed with the POR. She stated they followed up with the facility on 6/13/24. During an interview on 6/13/24 at 2:40 PM, the Activity Director stated she went in resident's rooms to provide activities. She stated there are signs posted outside of resident rooms when on isolation or EBP. She stated the facility in-serviced her on infection control, CRPA, donning and doffing PPE, hand hygiene, when to wash hands and when to use hand sanitizer, the bright orange sign posted for contact precaution, the PPE used for isolation and when to use it She stated the facility provided an in-service about staff using disposable cups for containers for residents that are on contact isolation precautions. That staff cannot remove items for the resident rooms if on isolation, staff needs to use foam cups to take water or ice in rooms and throw away in rooms. That staff should not bring items out of rooms for residents on isolation. That any non-disposable items that were used in an isolation room would need to be cleaned and sanitized with k-quat. During an interview on 6/13/24 at 2:45 PM, LVN A stated the facility provided in-service over contact isolation, infection control, EBP, equipment used in isolation rooms, cleaning and disinfecting those items before use in another room or with resident, disposable drinking cups, and meal containers, how to serve a meal to a resident on isolation, PPE used for isolation verses EBP and when to use PPE, hand hygiene, when to wash hands, when staff can use hand sanitizer, and to practice hand hygiene before entering rooms and exiting rooms. LVN A stated staff should use foam cups when refilling water for residents on isolation, to take the refill in the room and dispose of the foam cup, not bring items out of the room. The facility will use orange sign posted outside of resident rooms for contact isolation and signs for EBP will be posted outside of resident rooms. During an interview on 6/13/24 at 2:53 PM, the SW stated the facility provided an in-service on EBP and there were signs posted outside of the door and staff were to sanitize their hands before they enter the room and when they exit the room and if any care is provided PPE must be worn; contact isolation and an orange sign would be posted outside of the resident room, staff would have to perform hand hygiene then put on PPE, gown, gloves and a mask before they entered the room, remove the PPE before they exit the room and preform hand hygiene. If a resident was on contact isolation 676028 Page 11 of 12 676028 06/13/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Immediate jeopardy to resident health or safety precautions staff cannot remove anything from the room like a cup. If the resident requested a refill or a drink staff would need to use a disposable foam cup and take the drink or refill to the resident in the room and throw away the cup in the room. The SW stated that the facility provided in-service over hand hygiene when to was hands and when sanitizer can be used and how to wash hands. The SW stated the facility provided in-service over infection control and CRPA and to follow the policy. She stated that any reusable item that had to be used in a resident room on isolation would need to be[TRUNCATED] Residents Affected - Some 676028 Page 12 of 12