Health inspection·January 30, 2024

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 infections for 4 of 5 residents (Residents #1, #2, #3 and #4,) reviewed for infection. Residents Affected - Some 1. LVN C failed to clean the blood pressure cuff between Residents #1, #2, #3 and #4. 2. LVN C failed to clean the pulse oximeter between Residents #3 and #4. These failures could place residents at risk of cross contamination and exposure to infectious diseases. The findings include: During an observation on 01/30/24 from 9:06 AM through 10:35 AM of blood pressure checks, pulse oximeter checks, and medication pass with LVN C revealed the following: * LVN C sanitized hands, walked into Resident #1's room, put on gloves and did not sanitize the blood pressure cuff. LVN C took Resident #1's blood pressure, disposed of gloves and placed the blood pressure machine on top of medication cart. LVN C administered medications and washed hands. LVN C did not sanitize the blood pressure cuff before proceeding to Resident #2's room . *LVN C sanitized hands, walked into Resident #2's room and put on gloves. LVN C did not sanitize the blood pressure cuff. LVN C took Resident #2's blood pressure, disposed of gloves and placed the blood pressure machine on top of medication cart. LVN C administered medications and washed hands. LVN C did not sanitize the blood pressure cuff before proceeding to Resident#3's room. *LVN C sanitized hands, walked into Resident #3's room and put on gloves. LVN C did not sanitize the blood pressure cuff and pulse oximeter. LVN C took Resident #3's blood pressure, pulse and oxygen saturation. LVN C disposed of gloves, placed the blood pressure machine on top of medication cart, administered medications and washed hands. LVN C did not sanitize the blood pressure cuff and pulse oximetry before proceeding to Resident #4 room. *LVN C sanitized hands, walked into Resident #4's room and put on gloves. LVN C did not sanitize the blood pressure cuff and pulse oximeter. LVN C took Resident #4's blood pressure, pulse and oxygen saturation disposed of gloves, placed blood pressure machine on top of medication cart, administered medications and washed hands. LVN C did not sanitize the blood pressure cuff and pulse oximetry . Page 1 of 2 676268 676268 01/30/2024 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and observation on 01/30/24 at 10:33 AM, LVN C stated he did not keep the wipes on the medication cart because staff would take them.Surveyor observed a container of santzation wipes at the nurse's station desk LVN C stated he wiped the cuff after every 3rd person LVN C then stated he thought he had used the wipes to wipe the blood pressure cuff and pulse oximeter. The State Surveyor asked about good practice or facility policy and LVN C did not respond. LVN C stated infection could be passed between residents by not saniitaton between residents During an interview on 01/30/24 at 12:40 PM, the DON stated blood pressure cuffs and pulse oximetry should be sanitized between residents to prevent the spread of infections. Record review of the facility policy, Cleaning and Disinfection of Resident Care -Items and Equipment, revised September 2022, reflected, D . Reusable items are cleaned and disinfected or sterilized between residents . 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 676268 Page 2 of 2