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, interviews, and record reviews, 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 disease and infection for 1 of 5 resident (Resident #1)
reviewed for infection control, in that:
Residents Affected - Few
CNA A did not change her gloves before putting on Resident #1's clean brief after cleaning the resident's
buttocks area.
This deficient practices could place residents at-risk for infection due to improper care practices.
The findings include:
Record review of Resident #1's face sheet, dated 07/06/2023, revealed an admission date of 01/10/2014,
and a readmission date of 11/23/2023, with diagnoses which included: Dementia (group of symptoms
affecting memory, thinking and social abilities severely enough to interfere with daily life, Alzheimer's
disease (a type of dementia that damages the brain and affects memory, thinking and behavior),
intracranial injury with loss of consciousness (head injury causing damage to the brain) and psychosis (loss
of contact with reality, includes delusions and hallucinations (seeing or hearing things that aren't there).
Record review of Resident #1's annual MDS, dated [DATE], revealed the resident had a BIMS score of
03/15, which indicated severe cognitive impairment. The resident required extensive assistance to total care
of one to two person for most ADL's and was frequently incontinent of bowel and bladder .
Review of Resident #1's comprehensive care plan dated 09/26/2022 revealed Focus .Incontinent of bowel
and bladder.
Observation on 07/06/2023 at 12:20 p.m. of CNA A as she performed incontinent care for Resident #1 in
his bedroom revealed she did not change gloves and sanitize her hands between taking off the dirty brief,
cleaning the resident's peri area and buttocks and putting on the clean brief.
During an interview with CNA A on 07/06/2023 at 12:25 p.m., CNA A confirmed she did not sanitize her
hands and change gloves after she cleaned Resident #1's perineum and buttocks prior to putting on the
resident's clean brief. CNA A stated her gloves were not visibly soiled and CNA A confirmed she
understood the risk of infection for the resident and confirmed she received infection control training.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676173
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview with the ADON on 07/06/2023 at 11:18 a.m., the ADON confirmed that CNA A should
have sanitized or wash her hands and changed gloves prior to putting on Resident #1's clean brief. The
ADON confirmed the risk of infection and cross contamination for the resident. The ADON confirmed
nursing staff were trained on infection control.
Record review of CNA A's, CNA Proficiency Audit, dated 02/02/2023 revealed CNA A received competency
for incontinent care and hand washing.
Record review of the facility Infection Control Policy and Procedure Manual updated 03/2023 revealed
Implement PPE usage practices consistent with accepted standards of practice to reduce the spread of
infections and prevent cross-contamination.
Record review of the facility's policy, Fundamentals of Infection Control Precautions, dated 2019, revealed,
The following is a list of some situations that require hand hygiene: [ .] After contact with a resident's
mucous membrane and body fluids or excretions. [ .] after removing gloves. [ .]
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 2 of 2
