Health inspection·April 10, 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 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 (Residents #1) out of 3 residents reviewed for infection control, in that: Residents Affected - Few The facility failed to ensure CNA B contained the dirty wipes after cleaning Resident #1; CNA B threw the used wipes across Resident #1 to the trash can located at the opposite side of the bed whilre providing incontinent care to Resident #1. The facility failed to ensure that CNA C did not put clean gloves in her scrubs pocket during incontinent care for Resident #1. These failures could increase the spread of infection and place residents living in the facility at risk of exposure to infections. Findings include: Record review of face sheet revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses include need for assistance with personal care, hypertension, acute respiratory failure, overactive bladder, communication deficits, shortness of breath, muscle wasting, constipation, generalized anxiety disorder, cognitive communication deficit. Record review of MDS (minimum data set) dated 2/28/2024 revealed Resident #1 needed extensive assistance for ADL care and required one-person physical assistant. Record review of the care plan dated 3/10/2024 revealed Resident #1 had impaired functional mobility and required assistance with ADLs, with interventions included to assess the degree of functional impairment and assist resident with ADL's (Activity of Daily Living) based on the current level of mobility. On 04/08/2024 at 3:15pm in an observation, CNA B was providing incontinent care on Resident #1. CNA B was cleaning Resident #1 and she was throwing the wipes across the bed to the other side where the trash can was located, some of the wipes fell on the floor. CNA C was assisting CNA B during the incontinent care. CNA C removed gloves from her scrubs pocket and donned them during the incontinent care. On 04/08/2024 at 3:35pm in an interview with CNA B, she stated she had training on infection Page 1 of 2 676155 676155 04/10/2024 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few control during hiring with hands-on checkoffs, and she also had an in-service on infection control too. She stated the deficient practice could potentially spread microorganisms into the air and cause contamination. On 04/08/2024 at 3:39pm in an interview with CNA C, she stated she was trained on infection control when she was hired at the facility. CNA C verbalized the understanding that her pocket was not sanitized and thereby contaminated the clean gloves. On 04/08/2024 at 8:10pm in an interview with the DON, she said tomorrow (04/09/2024) would be an excellent day for training because they actually had skills checkoff tomorrow and they did check offs on everything that the CNAs did like peri care/incontinent care, hand washing, donning gloves, and all kind of infection control stuffs. She stated they did that training monthly or yearly depending on what was going on. She stated Everybody gets training tomorrow and skills checkoff, just in case they forgot all the rules and regulations about patient care. The DON stated the deficient practice placed residents at risk for cross contamination and infection. Record review of facility policy titled 'Infection Prevention and control policies and procedures' dated 02/17/2021 revealed in part, the infection prevention and control program consist of currently acceptable infection control standards practices and activities, and training provided to employees regarding hand hygiene, hand washing, universal standard and transmission based precautions, proper handling of linens, waste, equipment and supplies. 676155 Page 2 of 2