Health inspection·June 14, 2022

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 2 (Resident #27 and Resident #35) infection control, in that: Residents Affected - Few LVN B observed did not follow the facility's infection control policy and procedure of sanitizing blood pressure monitor after using on Resident #27 and before using it on Resident #35. This failure could place at risk of transmission of disease and infection. Findings included: Review of Resident #27's medical record reflected a [AGE] year-old woman admitted on [DATE]. Diagnoses included Schizoaffective disorder- bipolar type, Insomnia due to medical condition, personal history of other venous thrombosis (blood clots in the deep veins) and embolism ( blockage in an artery in the lung), muscle weakness (generalized), urinary tract infection site not specified, stress incontinence (female) (male), cough, nausea, dysphagia ( difficulty in swallowing), abnormalities of gait and mobility, unspecified lack of coordination, edema (swelling), unspecified, long term (current) use of anticoagulants. Review of Resident # 27's Medication Administration Record (MAR) for June 2022, reflected an order for CloNIDine HCl Tablet 0.1 MG as follows: Give 0.05 mg by mouth two times a day for hypertension hold for SBP<110 or DBP <60, and Notify MD. An observation of taking blood pressure using a wrist blood pressure monitor on 06/13/2022 beginning at 09:00 am, on residents with blood pressure related issues revealed LVN B failed to sanitize the wrist blood pressure cuff after using it on Resident #27 and before using it on Resident #35 until the surveyor asked her about it. Without sanitizing she kept the equipment on the medication cart and opened the medication cart drawers and operated the computer without sanitizing her hands. When asked her about the facility sanitation policies and procedure for hand and equipment sanitization, LVN B stated that all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. Then she searched for sanitizing wipes in the medication cart. Since there were no wipes available on the cart, she went to the storeroom and returned with a new packet of sanitizing wipe to sanitize the blood pressure monitor. Page 1 of 2 676473 676473 06/14/2022 Caraday of Lampasas 1000 E Ave J Lampasas, TX 76550

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 06/13/2022 at 09:30 am with LVN B, stated that she sanitized the blood pressure wrist cuff after she used it on the resident prior to the Resident #27. However, surveyor observed that there was no sanitation supply available on the cart at that time. When asked about touching the surfaces of the medication cart and computer keypad without sanitizing her hands after touching Resident #27, LVN B kept quiet . Residents Affected - Few An interview on 06/14/2022 at 2:00 pm with the DON revealed that her expectation was that the nursing staff follow facility policy/procedure for handwashing/sanitization and when using reusable medical equipment. The DON added that they have infection control training annually and in services on regular intervals related to infection control ( Eg. Hand washing). The facility identifies deficiencies in infection control practices through direct observations. In services provided to the relevant staff members when any deficiencies identified. Facility's policy Cleaning and disinfection of resident-care items and equipment dated October 2018 it was stated that Reusable items are cleaned between residents (e.g., stethoscopes, durable medical equipment) Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions 676473 Page 2 of 2