Health inspection·January 30, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some performing hand hygiene, and she left the room to go to Resident #2's room without performing hand hygiene. Observation on 01/30/24 at 2:52 PM revealed LVN A left Resident #1's room and went to Resident #2's room. LVN A did not disinfect the blood pressure cuff, nor did she perform hand hygiene. She checked Resident #2's vital signs and left the room without performing hand hygiene. She then went to Resident #3's room. Observation on 01/30/24 at 2:54 PM revealed LVN A left Resident #2's room and went to Resident #3's room. LVN A did not disinfect the blood pressure cuff nor did she perform hand hygiene before checking the resident's vital signs. She checked Resident #3's vital signs and left the room without performing hand hygiene or disinfecting the blood pressure cuff. She then went to Resident #4's room. Observation on 01/30/24 at 2:57 PM revealed LVN A checking Resident #4's vital signs. LVA A did not disinfect the blood pressure cuff or perform hand hygiene after leaving Resident #3's room. LVN A did not perform hand hygiene before checking the Resident #4's vitals, and she did not disinfect the blood pressure cuff before and after checking Resident #4's vital signs. Interview on 01/30/24 at 3:00 PM with LVN A revealed she was supposed to perform hand hygiene before and after each resident or between the procedures to prevent contamination and spread of infection. LVN A stated she forgot to perform hand hygiene, and she did not have any reason why she did not perform hand hygiene. LVN A stated she did not disinfect the blood pressure cuff because she did not have the disinfectant wipes. LVN A stated she was a new hire on her second day on the floor doing orientation. She stated she did not know where to get the wipes, and she did not ask the nurse she was orienting with. LVA A stated she had started from room [ROOM NUMBER], and she had not disinfected the blood pressure cuff for all the other residents and had not realized she was not disinfecting the blood pressure cuff until the surveyor inquired about handwashing and blood pressure disinfection. LVN A stated she was aware she was supposed to perform hand hygiene and disinfect the blood pressure cuff to prevent contamination and spread of infection. LVN A stated she had not done training on infection control in this facility but had training in other facilities. Interview on 01/30/24 at 3:18 PM with the ADON, who was on the floor, revealed LVN A was supposed to perform hand hygiene before and after checking vital signs for each resident and disinfect the blood pressure cuff between residents. He stated since LVN A was in orientation, she was supposed to be with the nurse orienting her or she could have asked for the disinfectant wipes. The ADON stated LVN A had done training in the facility on infection control, and she knew the risk of contamination. Interview on 01/30/24 at 3:18 PM with the DON revealed her expectation was that staff perform hand hygiene before and after contact with each resident. The DON stated she expected staff performing vital signs checks to disinfect the blood pressure cuff between residents. The DON stated the facility had trained all new hire staff on infection control. She stated it was one of their orientation programs that was offered, and they checked off all new hires before they started working on the floor. LVN A had a general orientation checklist completed on 01/11/24. She stated failure to wash hands and disinfect the blood pressure cuff could lead to cross contamination. Record review of LVN A's completed orientation checklist, dated 01/11/24, revealed she had completed infection control and prevention, hand hygiene and personal protective equipment training. Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 2 of 3 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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)

F 0880 policy, dated September 2022 reflected: Level of Harm - Minimal harm or potential for actual harm .Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC recommendations for the disinfection and the OSHA blood borne pathogens standard. Residents Affected - Some .5.Reusable items are cleaned and disinfected or sterilized between residents(stethoscopes ,durable medical equipment. Record review of the facility's Respiratory Virus .Prevention and Control policy, dated January 2020, reflected: This facility follows current guidelines and recommendations for the prevention and control of respiratory virus. 1. During the care of any resident, all staff shall adhere to standard and any other indicated precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. 2. 2. Hand hygiene: 3. a. Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. 4. b. Hand hygiene in healthcare settings will be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, soap and water, not alcohol-based hand rubs, will be used. 5. c. Supplies for performing hand hygiene are available throughout the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 3 of 3