Health inspection·October 18, 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 observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #54, #3, and #27) reviewed for infection control practices. Residents Affected - Some LVN B failed to sanitize the glucometer (instrument used for point-of care blood glucose testing) between 3 residents (Residents #54, #3, and #27) during medication administration. LVN B failed to utilize proper hand hygiene during point-of-care testing using a glucometer and insulin administration for 3 residents (Residents #54, #3, and #27). These failures placed the residents under her care at risk for exposure to possible transmission of communicable diseases and infections. Findings included: Resident #54 Review of Resident #54's undated face sheet indicated Resident #54 was a [AGE] year-old male who admitted to the facility 01/30/2023 with diagnoses including diabetes and candidiasis of the skin and nails (yeast infection of skin and nails). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated his cognition to be moderately impaired as indicated by a BIMS score of 9 out of 15 and requiring moderate to maximum assistance with most ADLs. Review of Resident #54's physician orders dated 09/19/2023-10/19/2023 indicated an order dated 04/15/2023 for Resident #5's blood glucose level to be checked 4 (four) times a day with additional instructions to administer doses of Humalog insulin according to a prescribed sliding scale (A sliding scale varies the dose of insulin based on blood glucose level). Resident #3 Review of Resident #3's undated face sheet indicated Resident #3 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, acute respiratory failure, low white blood cell count, and dementia. Page 1 of 5 675878 675878 10/18/2023 Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated her cognition to be severely impaired as indicated by a BIMS score of 7 out of 15 and requiring substantial to totally dependent assistance with most ADLs. Review of Resident #3's physician orders dated 09/19/2023-10/19/2023 indicated an order dated 06/05/2023 for resident #3's blood glucose level to be checked before meals and at bedtime daily with additional instructions to administer doses of Novolog insulin according to a prescribed sliding scale. Resident also had an order dated 06/25/2023 for 20 Units of Basaglar insulin to be administered daily at 11:30 AM. Resident #27 Review of Resident #27's undated face sheet indicated Resident #27 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of a history of urinary tract infections, prostate cancer, and dementia. Record review of Resident #27's Quarterly MDS assessment dated [DATE] indicated his cognition to be severely impaired as indicated by a BIMS score of 7 out of 15 and requiring partial to moderate assistance with most ADLs. Review of Resident #27's physician orders dated 09/19/2023-10/19/2023 indicated an order dated 02/11/2023 for resident #27's blood glucose level to be checked 3 (three) times daily at 06:30 AM, 11:30 AM, and 04:30 PM with additional instructions to administer doses of Aspart insulin according to a prescribed sliding scale. During observation and interview on 10/16/2023 starting at 11:09 AM, LVN B, without washing or sanitizing her hands, removed a glucometer (a handheld meter used to measure how much glucose is in the blood) and a lancet (a small, sterile needle used to obtain a blood sample to check blood glucose levels) from the drawer of her medication cart and set them on top of the cart. Using her fingers, she obtained a test strip from its container and without sanitizing the glucometer first, she inserted the test strip into the glucometer. Without washing or using an alcohol-based hand rub (ABHR), she put on a pair of disposable gloves, picked up the glucometer and lancet and entered Resident #54's room. LVN B obtained a blood sample from Resident #54's finger and applied it to the glucometer test strip. LVN B said Resident #54's blood sugar level was 210. LVN B returned to the medication cart, disposed of the lancet in a secure container, removed the test strip from the glucometer, set the glucometer on top of the medication cart, and removed her gloves. LVN B did not sanitize the glucometer prior to placing it on the cart nor did she cleanse her hands after removing the gloves. She checked the physician's order and said the resident was to receive 4 Units of insulin. She obtained the appropriate insulin from the medication cart and without washing or sanitizing her hands, she put on a pair of disposable gloves. Using an insulin syringe, LVN B obtained the appropriate dose of insulin and an alcohol wipe and re-entered Resident #54's room. She cleaned an area of his right upper arm and using her left gloved hand to anchor the arm, she used her right hand to administer the insulin injection. Still wearing gloves, she adjusted the Resident's sleeve and left the room and returned to the medication cart. LVN B disposed of the insulin syringe and alcohol pad and removed her gloves. After disposing of the gloves, she accessed the computer to document the blood sugar level and insulin administration. LVN B did not perform any type of hand hygiene after removing the gloves. LVN B did not perform hand hygiene prior to care, between glove changes, nor after provision of care. LVN B did not clean and disinfect the glucometer before and after use. Placing her bare hands on the cart, she pushed the cart to the room of the next resident (Resident #3) requiring point of care testing 675878 Page 2 of 5 675878 10/18/2023 Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140

F 0880 for blood glucose level. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 10/16/2023 at 11:21 AM, LVN B stopped at the doorway to Resident #3's room. Without washing or sanitizing her hands, LVN B put on a pair of disposable gloves, obtained a test strip, inserted it into the same glucometer used for Resident #54. She used her gloved hand to open the mediation cart drawer and obtain a lancet. She entered Resident #3's room, cleaned a finger with the alcohol pad, obtained a blood sample for the test strip, and said Resident #3's blood sugar level was 187. LVN B said Resident #3's blood sugar level did not require any sliding scale insulin dose but Resident #3 would be receiving a routine dose of 20 Units of Lantus insulin. LVN B returned to the medication cart, disposed of the lancet and test strip, set the glucometer on the cart, and removed her gloves. She put on a clean pair of gloves, obtained a bottle of insulin from the medication cart drawer and using an insulin syringe, obtained the scheduled dose of insulin. Using her gloved hand, she reached into the cart drawer and obtained an alcohol pad. LVN B returned to Resident #3 and using her gloved left hand, repositioned Resident's sleeve and anchored the left arm while administering the insulin injection with her right hand. LVN B repositioned Resident's sleeve and left the room. Upon returning to the cart, LVN B disposed of the insulin syringe and alcohol pad and removed her gloves. Without sanitizing the glucometer, she put the glucometer in the medication cart drawer and said she had to go to another hall for the next resident (Resident #27) requiring point of care testing for blood sugar level. LVN B did not perform hand hygiene prior to care, between glove changes, nor after provision of care. LVN B did not clean and disinfect the glucometer before and after use. Residents Affected - Some During observation and interview on 10/16/2023 at 10:35 AM, LVN B stopped at the doorway to Resident #27's room. Without washing or sanitizing her hands, LVN B put on a pair of disposable gloves, opened the medication cart drawer with her gloved hands, picked up the glucometer (same one used for Resident #3) from the drawer, obtained a test strip from its container, and inserted it into the same glucometer used for the previous two residents. She used her gloved hand to open the mediation cart drawer and obtain a lancet and alcohol pad. She entered Resident #27's room, cleaned his finger with the alcohol pad, obtained a blood sample for the test strip, and said Resident #27's blood sugar level was 120. LVN B said Resident #27's blood sugar level did not require any sliding scale insulin. LVN B returned to the medication cart, disposed of the lancet and test strip, set the glucometer on the cart, and removed her gloves. Without washing or sanitizing her hands, LVN B opened the medication cart drawer and put the glucometer inside. LVN B closed the mediation cart drawer, locked the cart, and pushed the cart the cart to the nurses' station. LVN B did not perform hand hygiene prior to care, between glove changes, nor after provision of care. LVN B did not clean and disinfect the glucometer before and after use. During an interview on 10/16/2023 at 12:25 PM, LVN B said she had not washed her hands nor used hand sanitizer at any time during the process of checking blood sugar levels and insulin administration. She said she had not cleaned the glucometer before nor after point-of-care testing nor between resident usage. LVN B said the glucometer should have been sanitized between residents and should have been cleaned before placing it on the cart and in the cart drawer after use. She said the glucometer could be contaminated with blood or other infectious agents. LVN B also said she should have washed her hands before and after wearing gloves. She said handwashing and cleaning the glucometer between residents was important to prevent and control the spread of infections. During an interview with the DON on 10/16/2023 at 01:34 PM, she said she expected the nurses to follow infection prevention and control practices during point-of-care testing using glucometers and when administering insulin. She said the nurses should wash their hands before and after glove use, 675878 Page 3 of 5 675878 10/18/2023 Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some between resident contacts, and before and after performing procedures. She said nurses should cleanse their hands and the glucometers before and after use to prevent the spread of infections. The DON said each nurse cart contained 2 (two) glucometers so the nurses could alternate glucometer use between residents, allowing for the required wait time after sanitizing a glucometer. Record review of the facility policy titled Obtaining a Fingerstick Glucose Level dated 06/2020 indicated the following: Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 3. Disinfected blood glucose meter (glucometer) with sterile lancet . Steps in the Procedure 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 19. Remove gloves and discard into designated container. 20. Wash hands. Record review of the facility policy titled Handwashing/Hand Hygiene dated revised on 03/2020 indicated the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions or complete hand hygiene with an alcohol-based hand rub: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice; d. Before and after performing any invasive procedure (e.g., fingerstick blood sampling). 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents. 675878 Page 4 of 5 675878 10/18/2023 Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140

F 0880 d. Before preparing or handling medications. Level of Harm - Minimal harm or potential for actual harm h. After handling used dressings, contaminated equipment, etc. 8. The use of gloves does not replace handwashing/hand hygiene. Residents Affected - Some Record review of the facility policy titled Administering Medications dated 04/11/2022 indicated the following: 23. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 675878 Page 5 of 5