Health inspection·August 20, 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 observations, interviews, and record reviews, 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 two (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN A wore the appropriate PPE and performed hand hygiene during wound care for Resident #1. 2. The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care for Resident #2. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 06/24/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were moderately impaired. His diagnoses included high blood pressure. The resident had a Stage III pressure ulcer present on admission. Review of Resident #1's Care Plans reflected:08/20/25 Resident had a pressure ulcer on his sacrum related to disease process.Facility interventions: Use Enhanced Barrier Precautions.Administer treatments as ordered and monitor for effectiveness. An observation and interview on 08/20/25 at 10:15 AM of Resident #1 revealed LVN A was preparing to do wound care. The resident had a Stage III sacral wound. The resident had a sign for EBP posted on the door. There was not a PPE bin by the door. LVN A entered the room and put on gloves. LVN A did not put on a gown. LVN A cleaned the sacral wound. It was surrounded by pink scar tissue. The resident had approximately a quarter-sized open wound. Unknown depth. There were no signs of infection. LVN A did not change gloves or perform hand hygiene after cleaning the wound. LVN A applied collagen and a border gauze to the sacral wound. LVN A removed her gloves and washed her hands. LVN A said EBP required staff to wear a gown, gloves, and a mask. LVN A said she did not know that Resident #1 was on EBP. She also said she had not been trained on EBP. LVN A said the risk to the resident if she did not wear a gown, change gloves, and perform hand hygiene was contamination. LVN A said the resident's wound was healing. An interview on 08/20/25 at 10:30 AM with MA B revealed EBP were used for, infections or something. She said Resident #1 was not supposed to be on EBP. MA B said Resident #1 would need a sign and PPE available if he was on EBP. 2. Review of Resident #2's Quarterly MDS Assessment, dated 05/31/25, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. He was usually understood and usually understood others. His diagnoses included kidney disease and cancer. The resident was dependent on staff for toileting. The resident was frequently incontinent of bowel and bladder. Review of Resident #2's Care Plans reflected:03/13/25 Resident had bowel/bladder incontinence related to disease process.Facility interventions included:Incontinent: Check as required for incontinence. Wash, rinse and dry perineum. An observation on 08/20/25 at 10:35 AM of incontinence care for Resident #2 revealed there was a PPE box outside of the door. There was no EBP sign posted. Resident #2 was lying in bed. He was awake, alert, and oriented. He said he had a wound on his bottom. Residents Affected - Some (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: 455727 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 455727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115 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)