Health inspection·January 13, 2026

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 program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident #1) of six residents reviewed for infection control CNA A failed to cleanse the perineal area (vaginal area), change her gloves, wash her hands and dispose of the soiled brief in a designated container during incontinent care for Resident #1. This failure could place residents at risk of cross contamination which could result in infections or illness. Findings included:Record review of Resident #1's face sheet dated 1/13/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of unspecified dementia (a brain condition effecting memory and daily decision-making skills), anxiety disorder and heart failure. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was always incontinent of bowel and bladder and dependent with toileting hygiene.Record review of Resident #1's care plan dated 12/20/2023 reflected that she had an activity of daily living self-care performance deficit related to limited range of motion in her hands/wrists. Interventions included TOILET USE: The resident is dependent on 1 staff for toileting needs. Incontinent care with disposable brief use.In observation of perineal care on 01/13/2026 at 1:30 p.m. CNA A and CNA B entered Resident #1's room. CNA A unfastened Resident #1's brief and had her roll over to CNA B to assist her with holding Resident #1 over. CNA A wiped Resident #1's buttocks with a wet wipe using multiple passes with the same wipe, throwing the soiled wipes and brief on the floor. CNA A then obtained a clean brief without washing her hands or changing her gloves and applied the clean brief. CNA A picked up the soiled brief from the floor and placed it in a plastic bag provided by CNA B. CNA A covered the resident up and lowered the bed. In an interview on 01/13/2026 at 1:55 p.m. CNA A stated she had been checked off on perineal care one time since she had started working at the facility about a year ago. She stated she should have cleaned the resident's front perineal area first prior to rolling her over and cleaning her buttocks. She stated she knew she should have wiped 1 time and changed the position on her rag changed her gloves and washed her hands between the dirty brief and clean brief. She stated she was just nervous. CNA A stated she was told not to put the brief in the trash can and that was a violation. She stated she should have placed the dirty soiled brief in a bag and not directly on the floor, she stated all those things would spread germs resulting in infections for residents. In an interview on 01/13/2026 at 2:10 p.m. the DON stated she had started at the facility about 1 month ago. She stated she had not had the chance to do CNA skills check offs and had a meeting planned with them to do that within the next few weeks. She stated she expected the CNAs to follow perineal care and the handwashing policy. The DON stated she and the ADON were responsible for monitoring CNA performance check offs. The staff were trained by the nurse managers for competence. The ADON was the infection preventionist. She stated that Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455591 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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)