Health inspection·May 15, 2025

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 measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #12, Resident #58, Resident #159, and Resident #160) reviewed for infection control. Residents Affected - Some RN A failed to disinfect vital signs equipment between each resident while performing morning medication administration for Resident #12, Resident #58, Resident #159, and Resident #160. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #12's face sheet, dated 5/14/2025, revealed Resident #12 was an [AGE] year-old female admitted on [DATE] with diagnoses of spine fracture and type 2 diabetes. Review of Resident #58's face sheet, dated 5/14/2025, revealed Resident #58 was an [AGE] year-old female admitted on [DATE] with diagnoses of critical illness myopathy (diseases related to the muscles), dementia and hypothyroidism (underactive thyroid). Review of Resident #159's face sheet, dated 5/14/2025, revealed Resident #159 was an [AGE] year-old female admitted on [DATE] with diagnoses of asthma and lack of coordination. Review of Resident #160's face sheet, dated 5/14/2025, revealed Resident#160 was a [AGE] year-old admitted on [DATE] with diagnoses of muscle wasting, asthma, and vitamin D deficiency. Review of Resident #160's care plan, dated 5/13/2025, revealed that the resident has a wound on right forearm and wound was at risk for infection. The goal listed for the wound was wound will be free of signs or symptoms of infection. In an observation on 5/14/2025 at 7:24am, RN A was measuring vital signs for Resident #12, Resident#58, Resident #159, and Resident #160 during morning medication administration. RN A did not disinfect blood pressure cuff and oximeter in between the 4 residents. In an interview on 5/14/2025 at 9:24am, RN A stated that she was nervous and forgot to disinfect vital signs equipment. She stated that the risk of not sanitizing equipment was the spread of infection between residents. Page 1 of 2 676407 676407 05/15/2025 Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 5/15/2025 at 12:15pm, DON stated that RN A approached her on 5/14/2025 and admitted that she failed to sanitize equipment in between residents. DON started in-service on disinfecting vital signs equipment immediately on the same day. DON stated that the risk of not disinfecting equipment can lead to spread of infection between residents which could affect residents and staff. Review of in-service record dated 5/14/2025, with training topic Disinfecting vital signs equipment between each resident revealed RN A and other nursing staff were included in the training. On 5/14/2025 at 12:00pm, attempt to review facility's policy on disinfecting equipment was unsuccessful. DON stated that the facility did not have a specific policy on disinfecting equipment. Review of facility's Infection Control Policy, dated 8/2024, revealed under Prevention of Infection section, facility implemented infection prevention by .educating staff and ensuring that they adhere to proper techniques and procedures. 676407 Page 2 of 2