Health inspection·July 30, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents. The facility failed to use an appropriate transfer for CR #1 from bed to wheelchair. This failure could place residents at risk for harm and further injuries. Findings included: Record review of the Face Sheet (no date) for CR #1 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heatstroke, sunstroke, and second-degree burns on both legs and abdomen. He was discharged from the facility on 09/14/2023. Record review of the admission MDS assessment dated [DATE] revealed CR #1 scored 6 of 15 on the BIMS assessment, indicative of severe cognitive impairment. CR #1 was totally dependent on two persons physical assist for bed mobility, transfers, dressing, and personal hygiene. CR #1 was incontinent of bowel and bladder. Record review of CR#1's care plan initiated 08/15/2023 revealed the following: Problems: (CR#1) requires EXT to Total Assistance with ADL functional needs, toileting, personal hygiene & grooming needs. Goals: Will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Interventions: Will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Assist with repositioning as appropriate. In a telephone interview on 07/01/2024 at 10:18 a.m., with a family member of CR #1 revealed concerns regarding CNA C providing inappropriate transfer technique to CR#1 while transferring from bed to wheelchair. The family member submitted copies of videos from the camera that had been inside CR #1's room. CR #1's family member said as per the nursing home documentation, CR#1 required full assistance, and there was another caretaker in the room who could have provided assistance. Additionally, a transfer board was available in the room, clearly visible on camera as well. In an interview on 07/01/2024 at 11:34a.m., with LVN Z, CNA D and CNA E. CNA D said staff were trained to use gait belt for safe transfer. LVN Z said gait belt reduced the risk of injury during resident transfers. Page 1 of 6 676207 676207 07/30/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Review of a video dated 09/08/2023 at 5:31 p.m., revealed CNA C entered CR #1's room. The video captured CNA C lifting CR#1 under his arms and inappropriately placing him into a wheelchair. Level of Harm - Minimal harm or potential for actual harm Record review CNA C's personnel file revealed staff was terminated. Residents Affected - Few Attempted telephone interview on 07/29/24 at 10:23a.m., with CNA C was unsuccessful. Review of a video and interview on 07/29/24 at 12:58p.m., the DON said, this transfer was an improper transfer, and that staff were not trained to complete such transfers on residents. The DON said there were two staff in the room in the video, both needed to assist with transfer using a gait belt to prevent bruising and injuries to the resident. Record review of facility's Transfers: Method, Equipment, and Preparation policy dated (Rev: 07/2014) revealed read in part: .General Principles: Use gait belt on all assisted transfers. Patient's shoulders or arms are not appropriate to pull, push or lift upon. Cup your hand under the gait belt for greater control . 676207 Page 2 of 6 676207 07/30/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #2) reviewed for incontinent care. -The facility failed to ensure CNA J properly cleaned Resident #2 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings included: Record review of the admission sheet (undated) for Resident #2 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (persistent problems falling and staying asleep), and constipation (passing fewer than three stools a week or having a difficult time passing stool). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the BIMS score was 08 out of 15, which indicated she was moderately impaired cognitively. The MDS revealed she required substantial/maximal assistance from staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. Section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #2's care plan, initiated 06/23/2023 revealed the following: Problems: (Resident#2) required LTD-EXT assistance with ADL functional mobility, toileting, dressing, personal hygiene, and overall care needs. Goals: (Resident#2) will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Interventions: Provide assistance with toileting and personal hygiene needs. Observation on 07/29/24 at 11:42 a.m., revealed CNA J provided Resident #2 with incontinence care. CNA J removed Resident #2's brief and tucked it under the resident's buttocks. CNA J did not spread Resident #2's labia to thoroughly clean the area and the resident's urinary meatus. In an interview on 07/29/24 at 12:12 p.m., with CNA J, she said she worked PRN at this facility. CNA J said she did not spread Resident #2's labia and clean the resident's meatus during incontinent care because I was nervous. She said the failure placed the resident at risk for infections. In an interview on 07/29/24 at 12:41p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care. She said CNAs were provided training and competency check offs upon hire, quarterly and as needed. No policy on incontient care was provided on exit. 676207 Page 3 of 6 676207 07/30/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0690 Level of Harm - Minimal harm or potential for actual harm Record review of facility's Incontinent Care Skills Checklist (Revised January 2015) read in part: .Female perineal Care 4. Separate labia with hand to expose urethral meatus. Use one stroke method to clean front to back. 5. Wash labia major and skin folds . Residents Affected - Few 676207 Page 4 of 6 676207 07/30/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

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 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 infection for 1 of 4 residents (Resident #2) reviewed for infection. Residents Affected - Few -The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #2. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding included: Record review of the admission sheet (undated) for Resident #2 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (persistent problems falling and staying asleep), and constipation (passing fewer than three stools a week or having a difficult time passing stool). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the BIMS score was 08 out of 15, which indicated she was moderately impaired cognitively. The MDS revealed she required substantial/maximal assistance from staff with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. Section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #2's care plan, initiated 06/23/2023 revealed the following: Problems: (Resident#2) required LTD-EXT assistance with ADL functional mobility, toileting, dressing, personal hygiene, and overall care needs. Goals: (Resident#2) will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Interventions: Provide assistance with toileting and personal hygiene needs. Observation on 07/29/24 at 11:42 a.m., revealed CNA J provided Resident #2 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J removed Resident #2's brief and tucked it under the resident's buttocks. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands and donned clean gloves. CNA J assisted Resident #2 turn to onto her left side to clean her buttocks. Resident had a small bowel movement. CNA J removed the soiled brief and discarded it into the clear bag sitting near resident's foot of bed. CNA J removed her soiled glove from her right hand and without washing or sanitizing her hands reached into her pocket and donned a glove on her right hand. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets. In an interview on 07/29/24 at 12:12 p.m., with CNA J, she said she worked PRN at this facility. She said she started working at this facility 3 months ago. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at her 676207 Page 5 of 6 676207 07/30/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0880 other job. She said she could not recall doing an in-service on infection control at this facility. Level of Harm - Minimal harm or potential for actual harm In an interview on 07/29/24 at 12:41p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care. She said CNA should have either washed or sanitized their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control. At this time the latest in-service on infection control/hand hygiene was requested. Residents Affected - Few Record review of facility's In-Service Training Report dated 04/07/24 revealed read in part: .Topic: Candida [NAME], Infection control, etc. Contents or summary of training: 1. Education 2. Handwashing 3. PPE 4. Cleaning/terminal clean 5. Infection control 6. Isolation types . This in-service was not signed by CNA J. Record review of the Infection Control Policy (Revised November 2017) revealed read in part: .1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, under a contractual agreement based upon the facility assessment. b. Staff, volunteers, visitors, and other individuals providing services will not be allowed to work if a communicable disease is diagnosed . Record review of the facility's Hand Hygiene policy (Revised August 2019) revealed read in part: . Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . 676207 Page 6 of 6