Inspection·July 18, 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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Residents Affected - Few LVN A failed to perform hand hygiene and prevent cross contamination of resident care items while providing blood sugar checks for Resident #1. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: Review of Resident #1's Face Sheet dated 07/18/20, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of retention of urine, malignant neoplasm of breast (breast cancer), constipation, and dementia (brain damage) Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required moderate assistance with most activities of daily living (ADLs) and was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #1's care plan dated 06/26/24 revealed a plan for hypoglycemia/hyperglycemic episodes related to diabetes mellitus. Its goal was for Resident #1 to be absence of signs of hypoglycemia (diaphoretic. Rapid pulse, confusion, lethargic, etc.) or hyperglycemia (increase thirst, dry mouth, blurred vision, fatigue, etc.) over the next 90 days. Observation of blood sugar checks on Resident #1 on 07/17/20 at 11:31 a.m. revealed LVN A did not wash hands or perform hand hygiene before start of care. She did not prepare a clean field before start of care to prevent cross contamination. LVN A placed the required supplies on top of the medication cart without wiping it down. The top of the table was visibly dirty. These supplies include glucometer, diabetic pins, test strips and alcohol pads. LVN A donned her gloves and picked up the supplies from the medication cart and entered Resident #1's room. She dumped the supplies on top of the resident's dressing table. She did not wipe the dressing table down. LVN A proceeded to prick the resident's finger which resulted in a blood sugar reading of 190 mg/dl (milligrams per deciliter). LVN A picked up her supplies and walked out of the room without washing her hands or performing hand hygiene. On her way out of Resident #1's room, the glucometer fell on the floor. LVN A picked up the glucometer and placed it on top of medication cart. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675279 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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)