Southern Specialty Rehab & Nursing

F-F880

ALLEGED ALLEGATION: Infection Control

Staff did not wear correct PPE while entering the room of a resident on isolation

Staff did not sanitize when entering and exiting the isolation resident room

Staff removed a non-disposable beverage cup from the infected resident room and filled from the community water station and used hand to operate the spout.

Staff placed infected resident cup on the nursing station contaminating the desk and placing immunocompromised residents at risk due to cross contamination.

Interventions:

The following in-services were initiated by the DON, ADON and regional nurse on 6/12/2024: Any staff member not present or in-serviced on 6/12/2024, will not be allowed to assume their duties until in-serviced.

o Staff will be Inservice on the following:

In-service staff on Infection Control Overview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 676028 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676028 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Specialty Rehab & Nursing 4320 W 19th St Lubbock, TX 79407

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 In-service staff on proper PPE use for MDRO isolation and Enhanced Barrier Precautions

Level of Harm - Immediate In-service staff with return demonstration related to hand hygiene and donning and doffing PPE. jeopardy to resident health or safety In-service staff on management of multi- use or non-disposable items leaving isolation rooms

Residents Affected - Some In-service staff on Carbapenem-resistant pseudomonas aeruginosa (CRPA)

In-service staff over management of all dietary items including beverage cups using disposable items only.

o Community water station was removed from service and sanitized prior to continued use.

o Nursing station was immediately sanitized to prevent cross contamination.

o Disposable cups will be placed behind the nursing station for use with MDRO isolation residents.

o All non-disposable cups were removed from the resident room.

o Disposable blood pressure cuffs, thermometer, stethoscope to be kept in room to prevent cross contamination.

o MDRO isolation signs will be printed in bright orange color to attract staff attention prior to entering resident rooms.

The medical director was notified of the immediate jeopardy situation on 6/12/2024 at 1745.

Monitoring

The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts.

The DON/designee will observe all MDRO resident rooms 3 times weekly to assure that non-disposable dietary items are not in resident room.

The QA committee will review findings and makes changes as needed.

During an observation on 6/13/24 at 10:25 AM revealed there was a bright orange contact precaution sign posted outside of room [ROOM NUMBER]. Staff observed donning PPE prior to entering the room. Disposable foam cups were observed in room [ROOM NUMBER]. The re-useable drinking cup was no longer in room [ROOM NUMBER].

During an observation on 6/13/24 at 10:30 AM revealed foam cups were at the nurse's station at the community water station for use.

During an observation on 6/13/24 at 11:24 AM revealed disposable equipment was observed in room [ROOM NUMBER] for staff use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 676028 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676028 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Specialty Rehab & Nursing 4320 W 19th St Lubbock, TX 79407

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 Record review of the facility in-service dated 6/12/24 titled Meal Service to isolated residents revealed: Absolutely no trays may enter isolation residents' rooms. One staff member may don gown, mask, gloves Level of Harm - Immediate and enter the resident room. A second staff member is to hand the disposable containers with resident meals jeopardy to resident health or to the staff member in PPE to give to resident. (76 staff had signed). safety

Record review of the facility in-serviced dated 6/12/24 titled Transfer Devices with Isolation Residents Residents Affected - Some revealed: Multi use, non-Disposable patient care devices must be sanitized upon completion of use. (i.e. Hoyer Lifts, Geri chairs). *K-Quat is to be used on non-disposable items. Other multi use patient care devices must remain in the resident's room and be sanitized upon completion of use. (i.e. BP cuff, stethoscope, pulse oximeter, glucometer). *Sani wipes to be used on these items. (71 staff signed).

Record review of the facility in-serviced dated 6/12/24 titled Hand Hygiene and policy revealed: Hand Hygiene, you may use alcohol-based hand cleaner or soap / water for the following: and examples of when to use. You must use soap/water for the following (alcohol-based hand cleaner is not recommended) examples given. (77 staff signed).

Record review of the facility in-serviced dated 6/12/24 titled Enhanced Barrier Precautions and policy revealed: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. (71 staff signed).

Record review of the facility in-serviced dated 6/12/24 titled MDRO Isolation revealed: Carbapenem Resistant Pseudomonas aeruginosa/Carbapenem resistant Acinetobacter baumannii. Residents are on contact isolation. Disposable medical equipment is required (stethoscope, blood pressure cuff, pulse oximeter, etc.). disposable cups for hydration (water is carried into the room in disposable cups). Donning and doffing PPE is required (Gown, mask and gloves). Rooms are clearly marked with bright isolation signage. Any staff attempting to enter these rooms must perform hand hygiene, and don masks, gloves, gowns. Prior to exiting the room masks, gloves, gowns are removed and disposed of, and hand hygiene preformed. All staff are required to follow all infection control policies. (74 staff signed).

Record review of the facility in-service dated 6/12/24 titled Refilling isolation beverages revealed: Residents

on contact isolation are served meals on Styrofoam plates and disposable utensils to prevent cross contamination to the dietary department or staff picking up trays. When managing a non-disposable drinking cups for these residents, they may not leave the room to be refilled. We may bring in a disposable cup with ice and water to refill the container. Those are disposed of inside of the resident room. If the non-disposable drink receptacle needs to be washed, and cannot be washed in the room, we will throw it away and get a new one. (71 staff signed).

Record review of competency test dated 6/13/24 and titled Putting on and Removing Personal Protective Equipment (PPE) revealed 45 tests were completed for staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 676028 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676028 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Specialty Rehab & Nursing 4320 W 19th St Lubbock, TX 79407

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 Record review of competency test dated 6/13/24 and titled Hand Hygiene revealed 48 tests were completed for staff. During an observation interview on 6/13/2024 at 11:24 AM with Resident #1 and family member Level of Harm - Immediate who was present in the room, revealed the resident was connected to a ventilator via her tracheostomy and jeopardy to resident health or was able to answer questions with a head shake or nod. When asked if all staff donned PPE prior to entering safety her room, Resident #1 nodded her head yes. When asked if staff were friendly with her while performing care, Resident #1 nodded her head yes. The family member also stated staff are very pleasant with the Residents Affected - Some resident always. The family member stated prior to the foam cups being brought to the resident's room yesterday, the staff would bring drinks to the room in a disposable, clear cup.

During an interview on 6/13/24 at 1:05 PM, the Dietary Aide stated she received in-serve on contact isolation precaution and the process that must be done before entering a resident room on those precautions. She stated she received in-service on EBP and when PPE would be needed. She stated there were signs posted outside the doors for EBP and bright orange signs posted for Contact precaution. She stated she was in-serviced on infection control and CRPA. She stated she was in-serviced on hand hygiene, and it must be performed prior to entering and exiting rooms; and how to preform hand hygiene, and staff completed competency check off for hand hygiene. She stated she was in-serviced on disposable containers used for residents on contact precautions, and that nothing could be removed from the room, as well as how a meal would be served, and that any items used that are not disposable must be cleaned and sanitized with K-quat sanitizer solution. She stated if she had any questions or concerns, she would ask staff before for assistance

before she entered a room.

During an interview on 6/13/24 at 1:36 PM, the MD Assistant stated the facility notified her of the IJ for infection control on 6/12/24 and the POR. She stated she informed the Medical Director and they agreed with

the POR. She stated they followed up with the facility on 6/13/24.

During an interview on 6/13/24 at 2:40 PM, the Activity Director stated she went in resident's rooms to provide activities. She stated there are signs posted outside of resident rooms when on isolation or EBP. She stated the facility in-serviced her on infection control, CRPA, donning and doffing PPE, hand hygiene, when to wash hands and when to use hand sanitizer, the bright orange sign posted for contact precaution, the PPE used for isolation and when to use it She stated the facility provided an in-service about staff using disposable cups for containers for residents that are on contact isolation precautions. That staff cannot remove items for the resident rooms if on isolation, staff needs to use foam cups to take water or ice in rooms and throw away in rooms. That staff should not bring items out of rooms for residents on isolation. That any non-disposable items that were used in an isolation room would need to be cleaned and sanitized with k-quat.

During an interview on 6/13/24 at 2:45 PM, LVN A stated the facility provided in-service over contact isolation, infection control, EBP, equipment used in isolation rooms, cleaning and disinfecting those items

before use in another room or with resident, disposable drinking cups, and meal containers, how to serve a meal to a resident on isolation, PPE used for isolation verses EBP and when to use PPE, hand hygiene, when to wash hands, when staff can use hand sanitizer, and to practice hand hygiene before entering rooms and exiting rooms. LVN A stated staff should use foam cups when refilling water for residents on isolation, to take the refill in the room and dispose of the foam cup, not bring items out of the room. The facility will use orange sign posted outside of resident rooms for contact isolation and signs for EBP will be posted outside of resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 676028 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676028 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Specialty Rehab & Nursing 4320 W 19th St Lubbock, TX 79407

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 During an interview on 6/13/24 at 2:53 PM, the SW stated the facility provided an in-service on EBP and there were signs posted outside of the door and staff were to sanitize their hands before they enter the room Level of Harm - Immediate and when they exit the room and if any care is provided PPE must be worn; contact isolation and an orange jeopardy to resident health or sign would be posted outside of the resident room, staff would have to perform hand hygiene then put on safety PPE, gown, gloves and a mask before they entered the room, remove the PPE before they exit the room and preform hand hygiene. If a resident was on contact isolation precautions staff cannot remove anything from Residents Affected - Some the room like a cup. If the resident requested a refill or a drink staff would need to use a disposable foam cup and take the drink or refill to the resident in the room and throw away the cup in the room. The SW stated that the facility provided in-service over hand hygiene when to was hands and when sanitizer can be used and how to wash hands. The SW stated the facility provided in-service over infection control and CRPA and to follow the policy. She stated that any reusable item that had to be used in a resident room on isolation would need to be cleaned and disinfected with k-quat before it could be used with another resident or in another resident's room.

During an interview on 6/13/24 at 3:15 PM, Housekeeper B stated she had been in-serviced on infection control. She stated she was in-serviced this morning on hand hygiene, abuse, how to clean resident with cotton balls. She stated she must wash hands and put on a gown, gloves before entering and remove PPE and sanitize hands before exiting for rooms on enhanced precautions. She stated rooms that have contact precautions have an orange sign outside the door. She stated for those rooms she must wash hands, put on

a gown, gloves, and mask before entering and remove all PPE and sanitize hands before exiting. She stated

she is not aware of any residents having falls recently.

During an interview on 6/13/24 at 3:48 PM, the Physical Therapy Assistant stated she had worked at the facility for 2 years. She stated she has received several in-services today. She stated she washes her hands when working with residents on isolation precautions and wears PPE. She stated contact precautions mean

she cannot take anything out of the resident's room and must use K-Quat to sanitize any equipment going in and prior to exiting the room. She stated rooms that have contac [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 676028