Garrison Mem Hosp Nsg Fac

F-F658.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 355115 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355115 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garrison Mem Hosp Nsg Fac 407 3rd Ave SE Garrison, ND 58540

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39685 potential for actual harm Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of Residents Affected - Few infection control and prevention for 2 of 8 sampled residents (Resident #5 and #13) and 1 supplemental resident (Resident #6) requiring stand lift transfers. Failure to practice infection control standards related to disinfection of equipment has the potential to spread infection throughout the facility.

Findings include:

Review of the facility policy titled Patient Multi-Use Devices, occurred on 02/27/25. This policy, dated February 2011, stated, . As part of the infection control prevention program, all patient/resident multi-use medical devices must be disinfected between patient/resident uses. These include but are not limited to . Mechanical lift devices .

- Observation on 02/24/25 at 1:40 p.m. showed a certified nurse aide (CNA) (#8) transferred Resident #6 from the toilet to a wheelchair using a stand lift. After completing the transfer, the CNA failed to sanitize the lift. When asked if there was a policy for sanitizing the lifts, the CNA (#8) replied, housekeeping does that.

- Observation on 02/24/25 at 3:58 p.m. showed two CNAs (#7 and #8) transferred Resident #13 from the toilet to a wheelchair using a stand lift. After completing the transfer, the CNAs failed to sanitize the lift and pushed it to another resident's room.

- Observation on 02/24/25 at 4:10 p.m. showed a CNA (#7) and a nurse (#6) transferred Resident #5 from

the toilet to a wheelchair using a stand lift. After completing the transfer, the nurse (#6) failed to sanitize the lift and pushed it to a storage room.

During an interview on the afternoon of 02/25/25, an administrative staff member (#11) provided a Lifts and Stands Maintenance Record showing housekeeping cleans the lifts twice a month and stated, But staff clean them after each use.

During an interview on 02/27/25 at 12:00 p.m., an administrative nurse (#2) stated she expected staff to sanitize the lift between resident use.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 355115