Health inspection·January 16, 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 observations, interviews, and record review, the facility failed to maintain infection prevention and control designed to provide a safe and sanitary environment to help prevent the transmission of infections for 1 of 7 residents (Resident #1) reviewed for infection control. Residents Affected - Few CNA A did not wear required protective equipment, for infection control, while providing services to Resident #1 in Resident #1's room. This failure placed residents in the facility at risk of exposure to infections. Findings included: RR of Resident #1's AR, 1/16/2025, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. She was diagnosed with Influenza (a contagious respiratory illness caused by a virus.) RR of Resident #1's CCP reflected a Focus Area, initiated on 1/13/2025, for isolation and droplet precautions R/T influenza. The Goal, initiated on 1/13/2025, reflected the resident would have no influenza related complications. The Intervention, initiated 1/13/2025, delegated facility staff to intervene in manners related to Influenza for 2 days. RR of a Resident #1's PN, dated 1/15/2025 at 8:25 AM, reflected Resident #1 remained on droplet precautions for influenza. OBS and RR on 1/15/2025 at 10:15 AM revealed CNA A in Resident #'1's room. CNA A was standing at the foot of Resident #1's bed verbally engaged with Resident #1 while folding a blanket. RR of an 8.5 inch by 11- inch sign posted to Resident #1's door frame, reflected [Isolation Droplet.] Donning (put on) gown, mask, goggles/shield, and gloves. Doffing (take off) gloves goggles/shield, gown, and mask. Keep bio-hazard box (box for contaminated equipment) in room. CNA A was not wearing any protective equipment. INT on 1/15/2025 at 1:15 PM with CNA A revealed she was in Resident #1's room on 1/15/202 at 10:15 AM. The Isolation Droplet sign had been on Resident #1's door for a couple of days. She stated she was not providing any care that required touching the resident, so she only sanitized her hands prior to entering the room. She did not think she needed to have on a gown, gloves, mask, and face shield for infection control purposes just to enter the room. CNA A acknowledged she risked exposure to Resident #1's Influenza and passing that Influenza to other staff and residents. OBS on 1/16/2025 at 9:55 AM reflected Resident #1 in her room being assessed by NP A. Resident #1 Page 1 of 2 676047 676047 01/16/2025 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0880 no longer had an Isolation Droplet sign on the frame of her door. Level of Harm - Minimal harm or potential for actual harm INT on 1/16/2025 at 10:10 AM with NP A revealed Resident #1 admitted to the facility on [DATE], from the community, with active Influenza on Droplet Isolation precautions. NP A stated Droplet Isolation precautions were used to protect other people in the facility, such as staff and residents, from contracting Influenza and transmitting it to others. As of 1/16/2025, Resident #1 was no longer on Droplet Isolation; Resident #1 was not showing signs or symptoms of active Influenza. Residents Affected - Few INT on 12/16/2025 at 2:08 PM with the DON revealed staff at the facility were trained by policy to follow Infection Control interventions. Staff knew who had Infection Control interventions in place by seeing (1) the sign located on the door; and (2) seeing the protective equipment in a container next to the door. Safeguards in place, to ensure nursing staff were wearing the appropriate protective equipment, were in-service trainings (facility staff group trainings) and observations by nursing and administrative staff. Staff who were not compliant with protective equipment received both redirection and retraining. Poor infection control practices could have resulted in an Influenza outbreak (facility wide cases) at the facility. The failure for staff to follow Infection Control guidance for Droplet Isolation fell on the individual staff member. Resident #1 was no longer on Droplet Isolation. There were no Influenza cases as of 1/16/2025. INT on 1/16/2025 at 2:47 PM with the ADM revealed that the facility staff were trained on Infection Control per policy. Staff were trained to know which residents had infections, and what combination of protective equipment to wear while interacting. There were signs posted on the residents' doors, boxes of protective equipment next to the residents' doors, annotations in the resident's care plans, and annotations in the residents' progress notes. If influenza spread, the facility could have an outbreak. There were no Influenza cases as of 1/16/2025.The failure for the staff to enter the room with the proper protective equipment, fell on the staff's lack of awareness. Safeguards in place to ensure staff wore the proper protective equipment were the policy, in-service trainings, and on-the-spot corrections. The last time the facility performed an in-service for Infection Control was on 1/3/2025. RR on 1/24/2025 of: http://www.cdc.gov/flu/spread/index.html reflected people with flu can spread it to others. Most experts think that influenza viruses spread mainly by droplets made when people with flu cough, sneeze, or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Putting physical distance between yourself and others can help lower the risk of spreading a respiratory virus. Less often, a person might get flu by touching a surface or object that has influenza virus on it and then touching their own mouth, nose, or possibly their eyes. RR on 1/24/2025 of: http://www.cdc.gov/flu/highrisk/index.hml reflected people at increased risk for influenza were adults 65 years and older; and those who lived in nursing homes and other long term-care facilities. RR of the facility's Infection Control Policy, dated 3/2020, reflected infectious diseases were those capable of being transmitted from one person to another. The list included Influenza. Droplet Isolation was a measure to follow to help prevent the spread of infectious diseases. Precautions may have included personal protective equipment. RR of a facility- initiated Infection Control In-Service Training, dated 1/3/2025, reflected 32 participants. CNA A was a staff member in attendance, marked by name and signature. 676047 Page 2 of 2