Health inspection·February 23, 2026

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 establish and 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 1 of 5 residents (Resident #1) reviewed for infection control.The facility failed to ensure LVN A followed Enhanced Barrier Precautions (EBP) when flushing the central line for Resident #1. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of the face sheet for Resident #1, dated 02/23/26 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominate side (right sided weakness/paralysis), and dementia (lasting, progressive decline in mental abilities). Record review of the significant change MDS assessment for Resident #1, dated 02/13/26 revealed Resident #1 received IV medications while a resident at the facility. Record review of the order summary report for Resident #1, dated 02/23/26, revealed an order: Enhanced Barrier Precautions: PPE required for high resident contact activities. Indication: implanted IV access.every shift with a start date of 02/21/26. During an observation on 02/23/26 at 9:35 AM, LVN A flushed the central line on Resident #1 with normal saline. LVN A did not wear a gown when providing care to Resident #1. A box with PPE inside was noted outside of Resident #1's room and a sign was noted on Resident #1's door stating, Enhanced Barrier Precautions. During an interview on 02/23/26 at 10:50 AM, LVN A stated she should have worn a gown when flushing the central line for Resident #1. LVN A stated she was not thinking about it and that was why she forgot. LVN A stated she was last trained on EBP during the last skills fair at the facility which happened sometime around October 2025. LVN A stated a potential negative outcome to the resident was a potential for infection or the spread of bacteria. During an interview on 02/23/26 at 10:54 AM, the DON stated he expected the nurses to follow EBP when flushing an IV line. The DON stated the staff were trained regularly on EBP at the facility and the last training was set for 2/20/26 but state walked into the building and the training was rescheduled. The DON stated the risk to the residents was possible infection. During an interview on 02/23/26 at 11:11 AM, the ADM stated he expected the staff to follow EBP if a resident was on it. The ADM stated the facility had signs and PPE boxes all around the facility to ensure staff were able to follow EBP. The ADM stated the risk to the residents with not following EBP was spreading infection. Record review of the facility education/training document, dated 12/17/25, revealed a topic regarding Enhanced Barrier Precautions. LVN A's name and signature were noted on the form. Record review of the facility policy titled, Infection Prevention and Control Program, with a revised date of 04/25 reflected the following: Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.Goals: Decrease the risk of Residents Affected - Few (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: 675925 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 675925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mildred & Shirley L. Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415 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)