Health inspection·December 1, 2023

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 one of five residents (Resident #1) reviewed for infection control. Residents Affected - Few 1. CNA A did not perform hand hygiene or glove changes after touching Resident #1's purple foot pad/foam on Resident #1's foot, nor did she perform hand hygiene during perineal care . This failure could place residents at risk for infection. The findings include: Record review of Resident #1's face sheet, dated 12/01/2023, reflected the resident was initially admitted to the facility on [DATE], and readmitted [DATE]. Resident #1 was an [AGE] year-old female with diagnoses which included: Acute Kidney Failure (kidney failure), Type 2 Diabetes mellitus (A chronic condition that affects the way the body processes blood sugar ) , Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and malignant neoplasm of left kidney (cancer left kidney). Record review of Resident #1's admission MDS, dated [DATE], documented a 14/15 BIMS score, which indicated the resident was cognitively intact. Resident #1 was coded to have an indwelling catheter. Resident #1 also required extensive assistance of staff to assist in activities of daily living. Record review of Resident #1's Comprehensive Care Plan, date initiated 12/13/2022, reflected Focus: Resident #1 has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through review date. Interventions: brief use: The resident uses disposable briefs. Change (Q 2 hrs.) and PRN. Clean peri -area with each incontinence . During an observation on 12/01/2023 at 3:16 PM, revealed CNA A applied two sets of clean gloves, followed by removal and adjustment of Resident #1's purple foot pad/foam, and continued by retrieving cleaning wipes, and began cleaning Resident #1's perineal area. CNA A did not perform hand hygiene nor glove changing after touching Resident #1's foot and prior to beginning perineal care. While CNA A performed perineal care, CNA A removed the first set of contaminated gloves, but did not perform hand hygiene when she completed cleaning Resident #1's perineal area and began cleaning Resident #1's gluteal fold area. During an interview on 12/01/2023 at 3:32 PM, CNA A stated by her changing her gloves throughout Page 1 of 3 676321 676321 12/01/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the perineal care would be an adequate form of hand hygiene. CNA A stated she was nervous, and usually just changed gloves when cleaning front (perineum) to back (gluteal folds). CNA A did not give a definitive answer when asked what could happened if hand hygiene was not performed. CNA A stated washing her hands was a way to keep infection from being passed on to the resident or staff. CNA A stated infection could affect the well-being of a resident. CNA A stated she performed hand hygiene before perineal care and after perineal care, and continued by stating she was not aware to perform hand hygiene during perineal care. CNA A did not give a definitive answer as to why she did not change her second pair of gloves. CNA A stated she was last in-serviced about hand hygiene about three weeks ago, CNA A stated she was given a competency check off yearly on perineal care . During an interview on 12/01/2023 at 3:59 PM, the DON stated the facility followed CDC guidelines regarding hand hygiene infection control. The DON stated CNA A after touching Resident #1's foot pad/foam, CNA A should have removed her contaminated gloves and performed hand hygiene prior to commencement of perineal care. The DON stated by not performing hand hygiene and changing gloves, CNA A potentially introduced infection by cross-contamination from Resident #1's foot to perineal area. The DON stated cross contamination of the microorganism that lived on the surface of Resident #1's skin into Resident #1's vaginal area could cause infection. The DON stated infection could potentially lead to urinary tract infections, or sepsis which could jeopardize the well-being of Resident #1's health. The DON stated once CNA A completed Resident #1's perineal care, CNA A should have removed her gloves, performed hand hygiene, applied new clean gloves, and continued with cleaning Resident #1's gluteal area. The DON reiterated the potential adverse reaction of cross-contamination and infection severity. The DON stated the ADON administers competency checkoffs upon hire, annually, and as needed. The DON stated the ADON in serviced the clinical staff on perineal care. Record review of the facility's Infection Control (Handwashing/PPE) in-service, dated 11/09/2023, reflected CNA A was in attendance. Record review of the facility's CNA Orientation Skills Checklist competency checkoff, dated 02/15/2023, reflected CNA A completed Infection Control: Handwashing/gloves and Personal care: peri-care/female. Record review of the facility's Perineal Care Policy, dated 10/24/2022, reflected: .6. Perform hand hygiene and put on gloves 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. 10. Change gloves if soiled and continue with perineal care Record review of the Hand Hygiene Policy, dated 10/24/22, reflected, .2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. (no table attached) . 6. The use of gloves does not replace hand hygiene. Record review of the facility's Peri-Care: Female procedure, undated, policy reflected, 676321 Page 2 of 3 676321 12/01/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 .2. Wash hands thoroughly; . Level of Harm - Minimal harm or potential for actual harm 9. With non-dominant hand separate and hold labia Residents Affected - Few 10. Remove gloves, perform hand hygiene. DON (put on) new gloves. Record review of the CDC Guidelines online at https://www.cdc.gov/handhygiene/providers/index.html, regarding Hand Hygiene in Healthcare Settings, dated January 8, 2021, reflected Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. 676321 Page 3 of 3