Health inspection·May 31, 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 observation, interview, and record review, 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 1 resident (Resident #1) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #1, CNA A touched the trash can with her bare hands and did not wash her hands before putting her gloves on and starting to provide care. CNA B did not sanitize or wash her hands in between change of gloves. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet, dated 05/30/2024, revealed an admission date of 03/10/2023, with diagnoses which included: Spondylolysis (Bony defect or stress fracture in the arch of a vertebra), Chronic respiratory failure (condition making it difficult to breath), Fibromyalgia (chronic widespread pain with fatigue), Type 2 diabetes mellitus (high level of sugar in the blood), Obstructive sleep apnea (sleep related breathing disorder), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function) and severe obesity. Record review of Resident #'1's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 15 indicating no cognitive impairment. Resident #1 required extensive assistance to total care and was always incontinent of bladder and bowel. Review of Resident #1''s care plan, dated 05/20/2024, revealed a problem of is always incontinent of bowel and bladder and a goal of Will remain clean, dry and odor free and no occurrence of skin breakdown will occur over the next 90 days Observation on 5/30/2024 at 10:16 a.m. while providing incontinent care for Resident #1, CNA A, after washing her hands, touched the trash can by the resident's bed to place trash bag in it. CNA A touched the trash can with her bare hands. CNA A did not sanitize or wash her hands before putting gloves on and started to assist CNA B with incontinent care for Resident #1. CNA A touched the cleaning wipes and the skin of the resident. CNA B changed gloves after cleaning the resident and before applying cream to the resident buttocks. CNA B, again, changed her gloves before placing new brief on Resident #1 and placing new bed linens under the resident but did not sanitize or wash her hands Page 1 of 2 676472 676472 05/31/2024 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0880 between change of gloves Level of Harm - Minimal harm or potential for actual harm During an interview on 05/30/2024 at 10:33 a.m., CNA A confirmed touching the trash can with her bare hands and putting gloves on without sanitizing or washing her hands. She confirmed the trash can was considered dirty and that she should have sanitized her hands before starting to provide care to Resident #1. CNA A confirmed receiving infection control training within the year. Residents Affected - Few During an interview with CNA B, on 05/302024 at 10:35 a.m., she confirmed not using sanitizer between change of gloves and confirmed she should have sanitized or washed her hands between changes of gloves. She confirmed receiving infection control training within the year. During an interview with the DON on 05/30/2024 at 10:37 a.m., The DON verbally confirmed CNA should sanitize or wash their hands after touching the trash can in a resident's room. She confirmed CNA should sanitize or wash hands between change of gloves while providing care to a resident. Further interview with The DON, revealed the ADONs were providing training on infection control and hand washing at least once a year. The DON revealed The ADONs also did skills checklist once a year for all the staff. The DON revealed The ADONS did a monthly hand hygiene audit of all staff per facility protocol Review of annual skills check for CNA A revealed CNA A passed competency for Incontinent care and infection control/hand washing on 03/22/2024. Review of annual skills check for CNA B revealed CNA B passed competency for Incontinent care and infection control/hand washing on 03/23/2024. Review of facility policy, titled Hand washing/Hand hygiene, dated August 2014, revealed Use an alcohol-based hand rub [ .] for the following situations: [ .] after contact with objects in the immediate vicinity of the resident, after removing gloves. 676472 Page 2 of 2