Health inspection·May 20, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 diseases and infections for one (CNA A) of two staff observed for infection control. Residents Affected - Few CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Observation of incontinence care on 05/19/2025 at 11:24 a.m. revealed CNA A used hand gel in the hallway and donned (placed on gloves & gown) clean gloves and gown. CNA A entered the room, Resident #1 was lying on his back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA A wiped the genitals, discarding the wipe in the trash bag. CNA A wiped the shaft of the penis and discarding the wipe in the trash bag, and then cleaned the head of the penis and discarding the wipe in the trash bag. CNA A positioned Resident #1 on his right side with the help of another staff member. CNA A wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA A completed cleaning the rectal area of bowel movement, discarding the wipe. CNA A wiped the right buttocks, which was soiled with urine, discarding the wipe. Repositioning Resident #1with her soiled gloves to his left side, CNA A cleaned the left buttocks, which was soiled with urine, discarding the wipe. CNA A assisted, with her soiled gloves, the other staff member to reposition Resident #1 on his back. CNA A pulled the clean brief up underneath him with the soiled gloves and fastened the brief, removing the soiled brief placing it in the trash. CNA A then pulled the clean sheet up on the resident. CNA A removed her dirty gloves did not wash her hands or use hand sanitizer, placed on new gloves, and continued to assist the other staff member to straighten Resident #1 clothing and his linens and blanket on the bed. CNA A removed her gloves and gown in the room and then washed her hands. In an interview on 05/20/2025 at 1:00 p.m., CNA A said she was to perform hand hygiene before and after the procedure and between changes of gloves. The glove changes should occur at the beginning and at the end of the incontinent care. She said she did not do it this time because she was nervous and talking. She stated the risk would be spread of infection. In an interview on 05/20/2025 at 2:45 p.m., the DON stated the expectation was to perform hand hygiene and glove changes before and after any care, and any time after removing dirty gloves. If hands are visibly soiled clean with soap and water, otherwise can use hand sanitizer. The DON stated the risk is not performing hand hygiene, would be cross contamination. The DON stated she would be doing Page 1 of 2 745056 745056 05/20/2025 Southern Oaks Therapy and Living Center 3350 Bonnie View Rd Dallas, TX 75216

F 0880 proficiency skills testing again starting next week. Level of Harm - Minimal harm or potential for actual harm Review of in-services reflected an in-service performed by the DON on 04/15/2025 covering hand hygiene and incontinent care. CNA A was reflected as to have attended the in-service. Residents Affected - Few Review of the facility's policy Handwashing/Hand Hygiene revised July 2012, revealed, Policy Statement The facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. B. before and after direct contact with residents .i. after contact with resident's intact skin, j after contact with bodily fluids .m. after removing gloves, n. before and after entering isolation precaution settings, . 9. The use of gloves does not replace hand washing/hand hygiene. Review of the facility' policy Infection Control Guidelines for all Nursing Procedures dated July 2012 reflected purpose: To provide guidelines for general infection control while caring for residents. General Guidelines 3. Employees must wash their hands .a. before and after direct contact with resident .d. after removing gloves ., 745056 Page 2 of 2