Health inspection·August 3, 2023

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 infection in 1 of 1 dining rooms. Residents Affected - Few -LVN A failed to maintain proper hand hygiene while passing meal trays to multiple residents in the dining room and before feeding a resident. -CNA C and LVN B failed to perform hand hygiene before sitting down to assist residents with eating. This failure had the potential to affects residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Observation on 08/03/2023 at 8:15am of Breakfast service being served in the dining room revealed LVN A scratched her nose, then proceeded to scratch her armpit and then took food tray without performing HH. LVN A delivered tray to resident, opened milk carton, took lid off of food and juice. LVN A returned tray to dirty window (area where dirty dishes are returned to kitchen to be washed) and went back to line for next tray and proceeded to take another tray from the window with no HH being performed. LVN A then set up food for 2nd resident, opening milk carton and removing lids to food and juice for this resident. LVN A left dining room and did not perform HH on way out of dining room. Observation on 08/03/2023 at 8:39am LVN A was standing next to table for a few minutes and then left dining room, returned a couple of minutes later. LVN A sat down next to Resident #1 and started to feed resident without performing hand hygiene. CNA C came to take the place of LVN B and did not perform HH before assisting Resident #2 with her remaining breakfast. No hand hygiene was performed by LVN B between getting another resident more cream of wheat from the kitchen, and returning to Resident #2, whom she was feeding. During an interview on 08/03/2023 at 9:14am, LVN A was asked what the protocol was for hand hygiene, she stated that anytime you have contact with a resident. LVN A was asked why hand hygiene wasn't performed during meal pass. LVN A stated that she was nervous and there was no reason for not performing hand hygiene, LVN A stated, I just didn't. During an interview on 08/03/2023 at 3:08pm, DON was asked what the protocol was for HH during tray (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 2 Event ID: 675282 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 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)