Health inspection·March 20, 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 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 diseases and infections for 4 of 5 residents (Residents #1, #2, #3 and #4) reviewed for infection control practices. Residents Affected - Some 1. The facility failed to ensure the ICP, ADON, DON, staff nurses and CNAs knew the proper placement of PPE carts. 2. The facility failed to ensure PPE carts were posted outside of the EBP rooms of Residents #1, #2, #3 and #4. These failures could place residents at risk of cross contamination and/or infection. Findings include: 1. Record review of Resident #1's face sheet, dated 03/20/25, revealed an [AGE] year-old-female with an original admission date of 10/07/24 and a current admission date of 01/13/2025. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS of 02, which indicated severely impaired cognition. The MDS also revealed Resident #1 had a urinary tract infection, urinary incontinence, and indwelling catheter. Record review of Resident #1's care plan, initiated 03/04/25, revealed a care plan for UTI with ESBL with interventions to maintain contact isolation and ensure to use appropriate PPE when providing care. Record review of Resident #1's physician orders, with a start date of 03/06/25, revealed an order for contact isolation for diagnosis of UTI with ESBL. During an observation on 03/19/25 at 8:36 AM of Resident #1's door and room, there was an EBP sign posted, but there was no EBP - PPE cart posted on the outside of Resident #1's room. Upon further inspection, it was noted there was an EBP - PPE cart located on the inside of the room with the middle drawer of the cart left open. 2. Record review of Resident #2's face sheet, dated 09/29/24, revealed an [AGE] year-old-male with an original admission date of 09/29/24 and a current admission date of 02/05/25. Page 1 of 4 676107 676107 03/20/2025 Corpus Christi Nursing and Rehabilitation Center 2735 Airline Rd Corpus Christi, TX 78414

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 12, which indicated moderately impaired cognition. The MDS also revealed Resident #2 had an indwelling catheter. Record review of Resident #2's care plan, initiated 03/20/25, revealed a care plan for EBP due to wounds and indwelling device. Residents Affected - Some Record review of Resident #2's physician orders, with a start date of 02/12/25, revealed an order to change Foley catheter as needed. It also revealed an order with a start date of 02/26/25 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk for MDR (residents with wounds or indwelling medical devices). During an observation on 03/19/25 at 8:36 AM of Resident #2's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #2's room. 3. Record review of Resident #3's face sheet, dated 03/20/25, revealed a [AGE] year-old-male with an original admission date of 02/15/24 and a current admission date 06/15/23. Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS of 13, which indicated intact cognition. The MDS also revealed Resident #3 had a feeding tube. Record review of Resident #3's care plan, initiated 01/04/24, revealed a care plan for a feeding tube, as well as a care plan initiated on 05/02/24 for EBP due to G-tube. Record review of Resident #3's physician orders, with a start date of 11/20/24, revealed an order for enteral feeds via G-tube. It also revealed an order with a start date of 05/01/24 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk for MDR (residents with wounds or indwelling medical devices). During an observation on 03/19/25 at 8:39 AM of Resident #3's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #3's room. 4. Record review of Resident #4's face sheet, dated 03/20/25, revealed a [AGE] year-old-male with an original admission date of 06/01/21 and a current admission date 12/15/22. Record review of Resident #4's care plan, initiated 03/20/25, revealed a care plan for EBP due to dialysis. Record review of Resident #4's physician orders, with a start date of 10/02/24, revealed an order for dialysis on Monday, Wednesday and Friday. During an observation on 03/19/25 at 8:41 AM of Resident #4's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #4's room. In an interview with CNA-A on 3/19/25 at 1:00 PM, she stated she could tell who was on precautions because usually there was a box outside the door or inside the door and a sign on the door, but they did use the centrally located green PPE carts if there was not a PPE cart by the resident's room. She stated PPE was to keep from transferring the infection from one resident to another, and it was a 676107 Page 2 of 4 676107 03/20/2025 Corpus Christi Nursing and Rehabilitation Center 2735 Airline Rd Corpus Christi, TX 78414

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lot easier to remember what PPE to put on when there was a PPE cart at the door to be able to get the supplies from. She stated she has not personally placed the PPE carts at or in residents' rooms, but she believed it was the person from central supply who put the carts out. She stated she was in-serviced on putting on the gown and gloves prior to going into the room to give care. In an interview with LVN-B on 3/19/25 at 1:15 PM, she stated you could tell by the sign on the door who was on EBP and contact precautions. There should also be a box outside the room which contained the PPE supplies which were needed for the precautions that the resident was on. She stated she did not notice there were no carts outside the rooms before today, and PPE carts should not be located inside the residents' rooms because they would be considered contaminated and create cross-contamination when the cart itself or the supplies had to come back out of the resident's room. In an interview with the ICP - ADON on 3/19/25 at 2:00 PM, he stated PPE carts should have been placed outside the room, but he was told by the facility's corporate office that with EBP you did not have to enter the room with PPE unless you were providing direct contact with the resident, so it was okay to store the PPE in a central location to the hall for all the EBP rooms. He stated with contact precautions you must put on the PPE prior to entering the room, and there was some confusion with whether to place the PPE carts inside or outside the contact isolation rooms. He stated that since the contact PPE carts were being placed inside the contact isolation rooms, they would have to be emptied, all the products inside of the cart disposed of, and the cart cleaned and sanitized before it could come out and be utilized for any other room. He stated it was mostly the CNAs and LVNs who had been placing the EBP and Contact precaution signs and PPE carts, and the staff were in-serviced and educated on the correct way to do it, but they continued to do it wrong. He also stated improper use of PPE, or not wearing any PPE, could cause cross-contamination and an increase of infections in the facility. In an interview with the DON on 3/19/25 at 4:20 PM, she stated there was a locally centralized cart that was utilized for EBP - PPE, and someone from the corporate office was the one who taught them to keep PPE in a central location. She stated they were told not to have PPE carts in the hall outside the rooms, which was why there was a centrally located cart for EBP-PPE, and that was also why the PPE carts for the contact isolation rooms were being placed inside the rooms. She stated if staff did not have access to or know the appropriate PPE to utilize, cross-contamination could occur, and infections could be passed and spread. The DON stated the ADONs and floor nurses were responsible for placing the PPE carts. Record review of CDC: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/24, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/19/25 at 4:35 PM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/contain Record review of Enhanced Barrier Precautions policy dated 04/05/24 revealed 2) Initiation of Enhanced Barrier Precautions: b. an order for enhanced barrier precautions would be obtained for 676107 Page 3 of 4 676107 03/20/2025 Corpus Christi Nursing and Rehabilitation Center 2735 Airline Rd Corpus Christi, TX 78414

F 0880 Level of Harm - Minimal harm or potential for actual harm residents with any of the following: wounds, indwelling medical devices, infection, and/or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. 3) Implementation of Enhanced Barrier Precautions: a. make gowns and gloves available immediately near or outside of the resident's room. Residents Affected - Some 676107 Page 4 of 4