Health inspection·June 20, 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 observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control in that: Residents Affected - Few CNA A did not sanitize or wash hands after touching contaminated items before feeding resident or touching residents' food, placing residents at risk of food contamination. This failure could place all residents at risk of getting sick from staff not performing proper hand hygiene. Findings Included: Record review of Resident #1's face-sheet dated 06/20/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Pressure ulcer of tailbone, stage 2, elevated white blood cell count, abnormalities of gait and mobility, anxiety disorder, Abnormal brain development (cerebral palsy) , high blood pressure, elevated level of fat particles in the blood, muscle weakness, difficulty swallowing, repeated falls and communication difficulty. Record review of Resident #2's face-sheet 06/20/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: abnormal deposits of protein in the brain, brain disease, repeated falls, difficulty swallowing, cancer, muscle weakness, communication difficulty and legal blindness. Record review of Resident #3's face-sheet 06/20/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia, communication difficulty, low potassium, abnormalities of gait and mobility, high blood pressure, difficulty sleeping, eating disorder, high sodium in the blood and difficulty swallowing. Record review of Resident #4's face-sheet 06/20/2024 revealed an [AGE] year-old female admitted to the facility on [DATE], Her diagnoses included: Dementia, history of falling, anxiety disorder, skin redness, high stomach acid, complications of skin bacteria , and other nonspecific skin eruption, Observation of residents on 6/20/2024 at 12:16 pm revealed CNA A was feeding Resident #1. CNA A stopped feeding Resident #1 and proceeded to adjust the bib of Resident # 2 without washing or sanitizing her hands. She then proceeded to take Resident #3's plate, that the resident had hanging half off the table and put it back on the table. CNA A did not wash or sanitize her hands. CNA A then proceeded to go to Resident #4 and open her drink without sanitizing or washing her hands. Page 1 of 3 676308 676308 06/20/2024 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with MA B on 06/20/2024 at 1:15 pm revealed that she was trained on hand hygiene. She stated that staff were supposed to wash their hands after every resident and not touch food until you have washed your hands. She stated that if staff do not wash their hands infections can spread. She stated she was trained on infection control. Interview with CNA A on 6/20/2024 at 1:31 pm revealed she had been trained on hand hygiene and infection control. She stated that staff were supposed to wash their hands before they touch a tray, anytime they touch something and when staff touch clothing. CNA A stated that if staff do not wash or sanitize their hands it could cause contamination of the food and the residents could get sick. She stated she did not was or sanitize her hands before and after helping residents was because she did not have sanitizer on her. Interview with LVN C on 6/20/2024 at 2:05 pm revealed she has been trained on infection control and hand hygiene. She stated that she was trained on how to wash hands and dry hands with disposable towel. She stated they are to use sanitizer for up to three residents then must wash with soap and water. She stated the risk of not washing your hands is the residents could get sick. Interview with the Director of Nursing on 06/20/2024 at 3:59 pm revealed she has been trained on infection control and hand hygiene. She stated the training covered hand hygiene, different diseases, and PPE. She said that she was the infection control preventionist. She stated her expectations were for staff to wash their hands all the time. She stated she would tell staff If you are wondering, wash your hands. She stated staff should wash their hands before and after patient care if hands are soiled and in between trays. She also stated staff should wash their hands just about all the time. he stated the outcome of a staff member not washing his or her hands was that residents may catch something, or germs could be spread. Record Review of the Nursing Policies and Procedures dated 07/01/2016, revealed standard precautions are recommended practice for the care of all patients and residents receiving care in the facility. Standard Precautions include hand hygiene before and after patient/resident contact. Record Review of Infection Prevention and Control Program and Plan Policy dated 05/15/2023 revealed proper hand hygiene/hand washing technique will be always accomplished when handwashing is indicated. Hand hygiene/hand washing is the most key component of preventing the spread of infection. Maintaining clean hands is important for patient/residents/visitors as well as staff. Record Review of Infection Prevention and Control Program and Plan Policy dated 05/15/2023 revealed the following : When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: 676308 Page 2 of 3 676308 06/20/2024 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0880 Level of Harm - Minimal harm or potential for actual harm Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Residents Affected - Few 676308 Page 3 of 3