Inspection·March 14, 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 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 disease and infections for one of three residents (Resident #1) reviewed for infection control practices. Residents Affected - Few CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings include: Record review of Resident #1's face sheet, dated 03/14/24, reflected an 81- year- old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included constipation, dysuria (discomfort when urinating), hemiplegia (partial paralysis) and hemiparesis (partial weakness). Record review of Resident #1's Quarterly MDS assessment, dated 03/07/24, reflected Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was occasionally incontinent of bladder. Observation of incontinence care for Resident #1 on 03/14/204 at 11:06 a.m. revealed CNA A washed his hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. He did not change gloves but continued to clean the resident. His gloves were visibly soiled with urine. He did not wash his hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A removed his gloves and picked up the trash. CNA A washed his hands before leaving Resident #1's room. In an interview on 03/14/24 at 11:16 a.m. with CNA A, he revealed he should have changed his gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated he had been in the facility for 18 months and received infection control training about a month ago. He said cross contamination was transferring germs to residents. CNA A noted the resident could acquire an infection when he did not follow good infection control practices which included changing gloves before retrieving the clean brief. Record review of the facility's infection prevention and control program policy, revised 04/12/23, reflected: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676034 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brady West Rehab & Nursing 2201 Menard Hwy Brady, TX 76825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)