Health inspection·February 27, 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 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 infection for 2 (Resident #1 and Resident#2) of 4 residents reviewed for infection control. The facility failed on 02/27/26 to ensure infection control procedures were followed when the ADON, the PRN-TN and CNA A provided wound care to Resident #1, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when CNA A provided peri care, transferred and changed linens for Resident #1, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when the ADON and PRN-TN provided wound care to Resident #2, who was on enhanced barrier precautions, without appropriate PPE.The facility failed on 02/27/26 to ensure infection control procedures were followed when CNA B provided peri care to Resident #2, who was on enhanced barrier precautions, without appropriate PPE.This failure could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet, dated 02/27/26?reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with but not limited to vascular Dementia (decreased b blood flow to areas of the brain), mild with other behavioral disturbance, other lack of coordination, scabies (contagious skin infestation caused by tiny mites) (10/02/25), dermatitis and legally blind as defined in USA. Record review of Resident #1's MDS, dated [DATE] reflected, his BIMS score was 14 which indicated no cognition impairment. Record review of Resident #1's care plan, undated, reflected Resident#1 required Provide wound care treatment order.Record review of Resident#1'onorders, dated 02/13/26 reflected, Wound Care Treatment Order: Xeroform, Type - Non pressure wound Stage - N/A Treatment Directions -Right upper back non pressure wound: Cleanse with NS pat dry, apply Xeroform, Calcium then cover with dry dressing three times a week an PRN. Every evening shifts every Tue, Thu, Sat for Wound. If anything, abnormal noted with the wound notify.Record review of Resident #2's face sheet, dated 02/27/26?reflected she was a [AGE] year-old female who was admitted on [DATE] and diagnosed with but not limited to active primary progressive multiple sclerosis (steady worsening of neurological function without distinct relapses or remissions), acute upper respiratory infection and other nonspecific skin eruption. Record review of Resident #2's MDS, dated [DATE] reflected, his BIMS score was 15 which indicated no cognition impairment. Record review of Resident #2's care plan, undated, reflected Resident #2's condition required Enhanced Barrier Precautions. EBP related to Urinary Catheter, Wound Care.Goal reflected, Infection control intervention to reduce the transmission of multidrug-resistant organisms.Resident #2's intervention included Staff must don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration via enteral tube or central Residents Affected - Some Page 1 of 3 675453 675453 02/27/2026 Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some line, trach care and wound care.Record review of Resident #2's order, dated 01/25/26 reflected, Clean the wound to Sacrum with NS, pat dry apply, Collagen, calcium alginate, and cover with Dry dressing daily and PRN. every evening shift for pressure wound. During an observation on 02/27/26 at 3:25 PM, Surveyor observed an enhanced barrier sign on Resident#1's and Resident#2's doors which reflected, a stop signs with the following instructions: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. DressingBathing/showeringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice Care use: central line, urinary catheter, feeding tube, tracheostomy.Wound care: any skin opening requiring a dressing.During an observation on 02/27/26 at 3:30 PM, the ADON asked Resident #2 if she was ok with wound care being provided now. Resident #2 stated yes and she wanted to be changed first. CNA B walked in the room and stated she would change Resident #2. The surveyor observed no gowns were in Resident #2's room or outside the door.During an observation on 02/27/26 at 3:40 PM, the surveyor observed an enhanced barrier sign outside of Resident #1's door. Surveyor knocked on Resident #1's door and as surveyor entered observed CNA A providing peri care with no PPE gown. The ADON, PRN-TN and surveyor entered the room. The ADON stood behind Resident #1, PRN-TN provided wound care to Resident #1 back while CNA A stood behind Resident #1 and assisted with pushing Resident #1 forward so PRN-TN could provide care to his wound. CNA A and PRN-TN transferred Resident #1 into bed. CNA A stated he changed Resident #1's linens. Surveyor observed no gowns in Resident#1 room or outside the door. CNA A, the PRN-TN, and the ADON wore gloves and washed their hands. The ADON, PRN-TN and CNA A did not put on disposable gowns while care was provided to Resident #1.During an observation on 02/27/26 at 4:00 PM, the surveyor observed the CNA B and the ADON put on gloves. The ADON and the PRN-TN provided wound care to Resident #2'S sacrum with no PPE gown. The PRN-TN and the ADON wore gloves and washed their hands. The ADON and the PRN-TN did not put on disposable gowns while care was provided to Resident #2.During an interview on 02/27/26 at 4:15 PM, CNA B stated she changed Resident #2 without the yellow gown. CNA B stated the gown was not in the room and she usually wore the gown.During an interview on 02/27/26 at 4:20 PM, PRN-TN stated she did wound care for 4 days. The PRN-TN stated staff wore gowns if the resident had covid, cough, or any kind of upper respiratory condition. The TN-PRN stated she was trained on infection control. The PRN-TN stated staff can transmit different germs/infections to other residents on our clothes and make residents sick. During an interview on 02/27/26 at 4:30 PM, CNA A stated he changed Resident #1's brief and changed his linens without a gown because the resident did not have a contagious infection/virus at this time. CNA A stated he was trained in infection control and did not think a gown needed to be worn. CNA A stated staff always wash hands and put on gloves when care was provided to residents. During an interview on 02/27/26 at 4:35 PM, the ADON stated gowns for residents with indwelling catheters, G-tubes, MDRO, wounds and Covid. The ADON stated gowns are worn to protect residents from cross contamination. The ADON stated all staff are responsible for following infection control policy. During an interview on 02/27/26 at 4:40 PM, Resident #2 stated staff usually wear the gowns when wound care and peri care was provided. Resident #2 stated she believed CNA B was rushed and forgot.During an interview and observation on 02/27/26 at 4:50 PM, the DON showed the surveyor three closets that had disposable gowns. The DON stated carts with PPE were placed outside the resident's door to be used when residents are in isolation. The DON stated the staff had access to the gowns in the closet to use. The DON stated gowns should have been used during wound care to prevent cross contamination. The DON stated the TN ensured PPE was available to staff and the TN was on vacation. The DON completed in service with nursing staff at 4:35 pm which reflected, 675453 Page 2 of 3 675453 02/27/2026 Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Enhanced barrier precaution (EBP) a set of infection control measures on nursing homes designed to reduce the spread of multi drug resistive organism before surveyor exited. During an interview on 02/27/26 at 5:15 PM, the Admin stated the TN was out for the past week and the usual staff were not here. The Admin stated the facility does work hard to provide the best care to the residents.Record review of the facility policy, titled Infection Control Guidelines for All Nursing Procedures, revised 11/23 reflected, .2. EBPs employ targeted gown and gloves use during high contact resident care activities when contract precautions do not otherwise apply.3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: a)dressing .e) changing linens;.f) changing briefs or assisting toileting; g)device care or use (central line, urinary catheter, feeding tube, etch); wound care(any skin opening requiring a dressing). 675453 Page 3 of 3