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 Page 1 of 2 455727 455727 08/20/2025 Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA C and CNA D put on gloves and gowns to provide incontinence care before entering the room. CNA C said the resident was on EBP. CNA C said the sign was posted, but another resident in the facility would walk around and take down the signs. CNA C assisted the resident to turn to his left side. His brief was soiled with bowel movement. CNA C began cleaning the bowel movement. CNA C changed gloves and said I'm supposed to use hand sanitizer, but I don't have it. I'm supposed to use it between each glove change. CNA C changed gloves, but did not perform hand hygiene. The sacral area had two pinpoint openings areas. CNA C cleaned the area thoroughly, removed her gloves, and washed her hands. CNA C put down a clean brief and the resident was turned to his right side. CNA D cleaned the resident's other side of buttocks, and the resident was turned to his back. CNA D cleaned the resident's penis and scrotum. CNA D did not change gloves or perform hand hygiene. CNA D used the soiled gloves to apply cream to the resident's peri-area and fastened the brief. CNA D removed her gloves and washed her hands. An interview on 08/20/25 at 10:55 AM with CNA C revealed she said she did not perform hand hygiene. She said she should have gone in and washed her hands. She said the risk to Resident #2 was a possible transfer of infection. An interview on 08/20/25 at 12:55 PM with CNA D revealed she knew to change gloves and perform hand hygiene during incontinence care. She said she did not because, there was a lot going on. CNA D said the risk to Resident #2 was infection control. An interview on 08/20/25 at 1:10 PM with ADON E revealed she was the infection preventionist. She said EBP were used for residents with wounds, indwelling devices, and tracheostomies. ADON E said EBP were important to reduce risk of spread of infection. ADON E said with EBP, staff were supposed to wear a gown, gloves, and face shield (if spills were possible). She said the staff were trained on EBP in August 2025. ADON E said a resident on EBP was supposed to have a sign on the door and PPE in close proximity. She said Resident #2 did not have a sign posted because another resident in the facility would take the signs down. She said everyone was responsible for ensuring signs were kept posted, and she did not know why the resident did not have a sign posted on 08/20/25. ADON E said staff were supposed to wear appropriate PPE for EBP. ADON E said staff were supposed to change gloves and perform hand hygiene during wound care after cleaning the wound. ADON E said failure to wear appropriate PPE, change gloves, and perform hand hygiene placed the residents at risk for infection. ADON E said if staff were not aware of a resident being on EBP, there was a risk of transmission of infection. Record review of the facility in-service, PPE Donning and Doffing and EBP, dated 08/10/25, reflected:LVN A did not sign the in-service.MA B, CNA C, and CNA D signed the in-service. Record review of the facility in-service, Infection Prevention - Hand Washing/Hand Sanitizer, dated 08/10/25, reflected:LVN A did not sign the in-service.CNA C and CNA D signed the in-service. Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: .3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: When and How to Clean Hands.Before or after caring for someone who is sick. 455727 Page 2 of 2