Health inspection·April 10, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her hands. CNA A and CNA B rolled Resident #1 on his left side. CNA A took a wet wipe and wiped Resident #1's rectal area and removed stool. CNA A removed the used brief from underneath Resident #1 and placed it in the trash. CNA A then took a clean brief placed it under the resident, while wearing the same soiled gloves that were used to wipe the resident's rectal area and removed the old brief. CNA B commented to CNA A she should have changed her gloves. CNA A removed the soiled gloves, sanitized her hands, and placed on a pair of new gloves, then applied Vaseline to Resident #1's coccyx/buttocks area, CNAs A and B positioned Resident #1 on his back and fastened the brief. CNA A and CNA B positioned Resident #1 to a comfortable position. CNA A and CNA B removed their PPE, placed it in the trash and removed the trash from Resident #1's room upon exit. During interview on 04/02/24 at 5:45 p.m., CNA A said she was aware she should have changed her gloves after she wiped the resident's rectum and removed stool. She said the gloves were considered soiled. She said she should have washed or sanitized her hands and applied new clean gloves. During an interview on 04/10/24 at 9:40 a.m., CNA A said she was aware she should have changed her gloves and washed or sanitized her hands when she performed incontinent care for Resident #1. She said she was trained in orientation, on 03/12/24, and after the incident on 04/02/24 on infection control and incontinent care. 2. Record review of Resident #2's face sheet, dated 04/11/24, reflected a female who was admitted to the facility on [DATE], she was [AGE] year old, and her diagnoses included obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow )and dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #2's quarterly MDS assessment, dated 02/22/24, reflected she was able to make herself understood and understood others, had moderate cognitive impairment (BIMS score of 11), utilized a walker and a wheelchair for mobility, had an indwelling catheter and was always incontinent of bowel. Record review of Resident #2's care plan 09/18/23 reflected Resident #2 was at risk for infection related to an indwelling catheter. Interventions included clean around catheter with soap and water or may use wipes as appropriate and report any sign of infection, wash hands before and after procedure. During an observation on 04/02/24 at 6:00 p.m., CNA D was assisted by CNA C and performed incontinent care for Resident #2. CNA D and CNA C entered Resident #2's room, washed hands and put on gloves and gowns (enhanced barrier precautions). CNA D explained care provided to Resident #2 and performed peri-care by wiping the Resident #2's peri area from top to bottom with wipes. CNA D then removed her gloves and washed/sanitized her hands and applied a new pair of gloves. CNA D used a wet wipe and wiped Resident #2's rectal area, then removed the old brief from underneath Resident #2 and placed it in the trash. CNA D then took a clean brief placed it under Resident #2, applied barrier cream, while wearing the same gloves that were used to remove the old brief. CNA D and CNA C positioned Resident #2 to a comfortable position. CNA D and CNA C removed their PPE, placed it in the trash and removed trash from room upon exit. During interview on 04/02/24 at 6:10 p.m., CNA D said she was aware she should have changed her gloves after she removed Resident #2's old brief. She said the gloves where considered soiled. She should have washed or sanitized her hands and applied new clean gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 2 of 3 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 interview on 04/02/24 at 6:12 p.m., CNA C said CNA D should have changed her gloves after she had removed Resident #2's old brief. During an interview on 04/10/24 at 9:15 a.m., the DON said staff should have changed gloves and performed hand hygiene per the facility's protocol for incontinent care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. She said staff were trained upon hire in orientation regarding the facility's protocol for incontinent care and as needed. Record review of the facility's, undated, Incontinent Care Skills Checklist reflected .9. Wash from front towards rectum, front to back, using clean stroke, repeat if necessary with a new wipe as all feces must be cleaned off. With a new wipe, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock. 10. Wash and sanitize hands. Apply clean gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 3 of 3