Health inspection·August 17, 2023

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for four (Residents #1, #2, #3 and #4) of five residents reviewed for infection control. Residents Affected - Some MA M failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #2, #3 and #4. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1's face sheet on 08/17/23 revealed Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of malignant neoplasm (form of cancerous tumor), Type 2 diabetes, hypertension (high blood pressure), disorder of water balance, and respiratory failure. Record review of Resident #2's face sheet on 08/17/23 revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Type 2 diabetes, hypertension, respiratory failure, and contusion of the left knee. Record review of Resident #3's face sheet on 08/17/23 revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hypertension, pneumonia (inflammatory condition of the lung), and heart failure. Record review of Resident #4's face sheet on 08/17/23 revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hypertension, chronic obstructive pulmonary disease (progressive lung disease), and hyperlipidemia (high cholesterol). Observation on 08/17/23 between 9:45 AM-10:20 AM of MA A revealed she failed to disinfect the reusable blood pressure cuff with a disinfecting wipe between blood pressure readings on Resident #1, Resident #2, Resident #3, and Resident #4. MA A cleaned the blood pressure cuff after medication administration for Resident #4 with disinfectant wipes from her medication cart. Interview on 08/17/23 at 10:20 AM with MA A revealed she was aware of the requirement to disinfect Page 1 of 2 675759 675759 08/17/2023 Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the blood pressure cuff between residents, but the presence of the surveyor made her nervous. She revealed that not disinfecting equipment between residents could cause infections to be passed from one resident to another. Interview on 08/17/23 at 10:23 AM with the ADON revealed she and the DON were responsible for training staff on infection control, hand hygiene, and disinfecting equipment. The ADON stated staff were expected to perform hand hygiene upon exiting every resident room. If equipment was used, staff were to disinfect after every use prior to using the equipment on the next resident. The ADON stated MA A should have disinfected the blood pressure cuff after every use to ensure she was not cross contaminating or passing infection from one resident to another. Interview on 08/17/23 at 11:45 AM with the DON revealed the expectation was that staff would disinfect all reusable medical equipment between each resident use, to avoid cross contamination. The DON stated staff had disinfecting wipes available to them. She revealed she completed a staff in-service training immediately on disinfection of reusable medical equipment. Record review of training for MA A revealed an in-service dated 08/17/23 entitled Infection Control with emphasis on COVID-19, Hand Hygiene, Disinfecting Blood Pressure Equipment before and after each resident. Review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, dated October 2018, reflected: .Resident-Care Equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current recommendations for disinfection revealed Reusable items are cleaned and disinfected or sterilized between residents. 675759 Page 2 of 2