Health inspection·March 12, 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 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 4 residents (Resident #1) observed for infection control. Residents Affected - Few LVN A failed to properly dispose of soiled dressings and guaze when she provided with Resident #1 with wound care. This failure could lead to cross contamination and infection. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0. The MDS reflected Resident #1 had skin conditions, and he had diagnoses of an open lesion and pressure ulcer/injury. Record review of Resident #1's care plan dated 02/26/25 reflected the following: Problem: [Resident #1] has a lymphademic wound [a condition where excess lymph fluid accumulates in the tissues] to left posterior lateral calf. Goal: [Resident #1] lymphademic wound to left posterior lateral calf will heal without complications. Implement: Apply dressings per MD order. Problem: [Resident #1] has a lymphademic wound to right posterior lateral calf. Goal: [Resident #1] will not acquire any new open areas. Approach: Avoid shearing resident's skin during positioning, transferring, and turning. Problem: [Resident #1] has a Stage 4 pressure [involves full-thickness skin and tissue loss, exposing underlying structures like muscle, tendon, or bone] area to sacrum [the triangular bone that connects the lumbar spine and the pelvis] Goal: [Resident #1] ulcer will heal without complications. Approach: Treatment per MD order. Observation on 03/12/25 at 10:07 AM revealed LVN A preparing to provide Resident #1 wound care. LVN A washed her her hands, put on gloves, disinfected the table, and left it to dry. She then explained the procedure to Resident #1. She removed her gloves and washed her hands. She then put all the supplies together. LVN A next washed her hands, put on PPE, and put the feeding pump on hold. LVN A then removed the old dressing on the resident's left lower leg (calf) that was soiled with drainage, Page 1 of 2 676067 676067 03/12/2025 Mira Vista Court 7021 Bryant Irvin Rd Fort Worth, TX 76132

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she discarded it in the trash can. She removed her gloves, washed her hands, and put on new gloves. She then cleansed the wound on the resident's left calf and discarded the used gauze with blood in the trash can. Next, she removed her gloves and washed her hands. She pat dried the wound, applied calcium alginate with silver, covered it with Kerlix, and dated the dressing 03/12/25. She then removed her gloves, washed her hands, and put on gloves. Nex, she removed the old dressing on the resident's right leg, and she discarded the soiled dressing in the trash can. She removed her gloves, washed her hands, and put on new gloves. She then cleansed the wound on the resident's right calf and discarded the used gauze in the trash can. She removed her gloves and washed her hands. She pat dried the wound, applied calcium alginate with silver, covered it with Kerlix, and dated the dressing 03/12/25. She then removed her gloves and washed her hands. LVN A positioned Resident #1 on his left side. She removed the old dressing on the resident's sacrum, and she discarded the soiled dressing with darinage in the trash can. She removed her gloves, washed her hands, and put on new gloves. She cleansed the wound on the resident's sacral area and discarded the used gauze in the trash can. She removed her gloves and washed her hands. She pat dried the wound, applied collagen mixed with anasept, covered it with an island border dressing, and dated the dressing 03/12/25. She then removed her gloves and washed her hands. Finally, she positioned resident with the bed in low position with the resident's call light within reach, and she left the room. The soiled dressings and guaze remained in the trash can in the resident's room and were not in a biohazard bag. Observation on 03/12/25 at 12:00 PM with LVN A revealed the soiled wound dressings remained in the trash can in Resident #1's room. Interview on 03/12/25 at 3:17 PM with LVN A revealed she was aware she was supposed to discard soiled wound care dressing in a biohazard bag while performing wound care for Resident #1. LVN A stated she got distracted by other staff knocking on the door, and she did not realize she was throwing the soiled dressing in the trash can. She stated failure to discard soiled dressing in a biohazard bag was that it could risk exposure to staff thus leading to cross contamination and infection. She stated she could not recall training on how to discard soiled wound dressings. Interview on 03/12/25 at 3:37 PM with the ADON revealed she expected staff to dispose of soiled wound dressings in a biohazard bag. The ADON stated discarding soiled wound dressing in the trash can expose a risk of contamination to other staff and could lead to infection. She stated the facility had done trainings on infection control. Record review of the facility training records reflected training dated 03/12/25 facilitated by LVN A reflected the training was over disposing infectous waste properly is crucial for infection control involving segregation, secure storage and special disposal methods. Record review of the facility's Infection Prevention and Control Policies and Procedures, dated May 2023, reflected: .Dressing change nonsterile, sterile and sterile wet dispose of dressing according to standard of practice and applicable regulations 676067 Page 2 of 2