Health inspection·July 31, 2025

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 diseases and infections for two (Resident #30 and Resident #33) of twelve residents observed for infection control. RN A failed to sanitize shared use equipment (blood pressure device and wrist cuff) before and after resident use with Resident #30 and Resident #33 on 07/30/2025. This failure could place residents at risk for spread of infection through cross-contamination.Findings included:Review of Resident #33's Face Sheet dated 07/30/2025 revealed she was a [AGE] year-old female admitted from an acute care hospital. Relevant diagnoses included acute cerebrovascular insufficiency (inadequate blood flow to the brain), vascular dementia (impaired cognitive function related to impaired blood flow to the brain), depression (mood disorder), and seizures (sudden, uncontrolled electrical disturbance in the brain). Review of Resident #33's Quarterly MDS dated [DATE] revealed she had a severe cognitive impairment with a BIMS score of 03. She used a walker and wheelchair for mobility and had no impairments to her upper and lower extremity. Resident #33 required setup or clean up assistance for eating, shower/bathing, and personal hygiene. Review of Resident #30's Face Sheet dated 07/30/2025 revealed she was an [AGE] year-old female admitted from an acute care hospital. Relevant diagnoses included dementia (decline in mental abilities), psychotic disorder (group of mental illnesses involving hallucinations and/or delusions), traumatic brain injury (external force that causes damage to the brain), schizoaffective disorder (mental health condition characterized by a combination of schizophrenia and a mood disorder), major depressive disorder (mental illness characterized by persistent sadness and loss of interest in activities), and altered mental status (change in a person's level of consciousness or cognitive function). Review of Resident #30's Quarterly MDS dated [DATE] revealed she was cognitively intact with a BIMS score of 13. She used a wheelchair for mobility and had no impairments to her upper and lower extremity. Resident #30 required supervision with toileting, shower/bathing, and personal hygiene. In observation of RN A on 07/30/2025 at 8:55 AM, she obtained Resident #33's vitals with the blood pressure device and wrist cuff and placed it on her right wrist. RN V then provided Resident #33 with her medications. RN A failed to sanitize the blood pressure device and wrist cuff prior to obtaining Resident #33's vitals. RN V then moved on to Resident #30 and obtained her vitals with the same blood pressure device and wrist cuff and placed it on her right wrist. RN V then provided Resident #30 with her medications. RN V failed to sanitize the blood pressure device and wrist cuff before and after obtaining Resident #30's vitals. In interview with RN A on 07/30/2025 at 9:39 AM, she stated she did not sanitize the blood pressure device and wrist cuff prior to Resident #30 because she only sanitizes the [blood pressure device and wrist cuff] every two people. When asked if the facility trained her to do this, she stated not really. When asked what can occur if shared use equipment was not sanitized between every resident use, she stated Residents Affected - Few Page 1 of 2 455733 455733 07/31/2025 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection control issues. Interview with ADON B on 07/31/2025 at 10:14 AM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Interview with the DON on 07/31/2025 at 10:28 AM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Interview with the Administrator on 07/31/2025 at 2:02 PM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Record review of facility policy Standard Precautions, undated, provided by the DON on 07/31/2025 at 10:35 AM revealed Standard precautions are based upon the principle that all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are intended to be applied to the care of all persons in all healthcare settings, regardless of suspected or confirmed presence of an infectious agent. Record review of facility policy, Fundamentals of Infection Control Precautions, rev. 2019, reflected 6. Resident care equipment and articles . 3. Non-invasive resident care equipment is cleaned daily or as needed between use . 455733 Page 2 of 2