Health 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: Page 1 of 2 676034 676034 03/14/2024 Brady West Rehab & Nursing 2201 Menard Hwy Brady, TX 76825

F 0880 : Level of Harm - Minimal harm or potential for actual harm This facility has established and maintains 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 as per accepted national standards and guidelines. Residents Affected - Few 4. Standard Precautions . b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy. 676034 Page 2 of 2