Health inspection·March 1, 2025

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 control program designed to prevent the development and transmission of disease and infection for 7 of 7 rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) reviewed for infection control. Residents Affected - Some The facility failed to ensure that staff had appropriate Personal Protective Equipment (PPE) readily available to wear when entering rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) on droplet precautions to prevent the spread of infection. This failure placed all residents, as well as employees and visitors, at risk of communicable diseases. Findings included: Observation of Hall 600 on 03/01/25 at 11:15 AM revealed Rooms #605 and #608 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 700 on 03/01/25 at 11:18 AM revealed Rooms #703 and #704 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 800 on 03/01/25 at 11:20 AM revealed rooms #801, #805, and #607 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. In an interview on 03/01/25 at 1145 AM, LVN A stated she was administering medications on Hall 800. LVN A stated there were residents with COVID-19 on that hall, and they were on droplet precautions. She stated she wore gloves and a mask when entering the rooms. LVN A stated she did not wear face shields and only wore her eyeglasses. She stated there were no face shields in the PPE bins outside of the room and she did not know where they were kept. In an interview on 03/01/25 at 1:35 PM with the Administrator and DON, the DON stated the protocol for staff providing care to residents on isolation was to wear PPE appropriate for the precautions in place. The DON stated PPE for droplet precautions included a N95 mask, face shield, gloves, and a gown if providing direct care. The Administrator stated all staff were expected to wear appropriate PPE when entering isolation rooms and the risk not wearing it could cause the spread of infection. The DON stated the facility currently had 7 residents with COVID-19. The DON stated all PPE bins should be stocked with all PPE, including face shields and she and the ADON were responsible for Page 1 of 2 676141 676141 03/01/2025 Matlock Place Health & Rehabilitation Center 7100 Matlock Rd Arlington, TX 76002

F 0880 ensuring this was done. Level of Harm - Minimal harm or potential for actual harm Observations on 03/01/25 of PPE bins on Hall 600, 700, and 800 revealed they were all stocked with face shields. Residents Affected - Some Review of facility's policy titled Infection Prevention and Control Program, dated 01/01/23, reflected in part the following: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of Centers of Disease Control's website, <https://www.cdc.gov/infection-control/media/pdfs/droplet-precautions-sign-P.pdf>, reflected the following: Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered (mask and face shield or goggles). 676141 Page 2 of 2