Inspection·November 30, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA A) of three staff members reviewed. Residents Affected - Few -CNA A failed to change her gloves and perform hand hygiene after providing incontinence care and prior to assisting Resident #4 with dressing and positioning back into her wheelchair. This failure could places residents requiring incontinent care at risk for cross-contamination and infection. Findings included: Observation of incontinence care on 11/29/2022 at 11:20 a.m. provided by CNA A revealed the ST was present and assisted with translation during the procedure. CNA A and ST washed their hands at the sink in the Resident #4's bathroom and donned gloves. CNA A placed a gait belt around the resident's waist. Resident sat in her wheelchair, which was rolled into the bathroom. CNA A assisted resident to stand, pivot and sit down on the toilet using the gait belt. Prior to sitting down, the CNA A pulled residents brief down. CNA A reported the brief was dry. Resident urinated while sitting on the toilet. CNA A assisted resident to stand up, and the resident was encouraged to hold onto a grab bar across from the toilet. CNA A used wipes to clean resident's peri and buttock area, using one wipe per swipe before discarding, and wiping from front to back. CNA A pulled residents brief and pants up. Resident was assisted back into her wheelchair by CNA A and ST. CNA A removed the gait belt from the resident's waist. CNA A removed her gloves, used hand sanitizer, and provided hand sanitizer to the resident and S.T. CNA A washed her hands at the sink in the residents bathroom. In an interview with CNA A on 11/29/22 at 11:30 a.m. she said she should have removed her gloves and sanitized her hands after she pulled Resident #4's pants up. CNA A said a potential problem with not removing her gloves after providing incontinence care was the possibility of putting germs in places she should not put them. CNA A said she had received training on hand hygiene within the last 2 months. In an interview with the DON on 11/29/2022 at 2:47 p.m. revealed her expectations regarding hand hygiene during incontinent care included gloves be changed anytime they were soiled, anytime they might be soiled, and anytime there was a question about them possibly being soiled. The DON said hand hygiene should be performed anytime you move from a dirty to a clean area. She said a potential problem with hand hygiene not being performed according to facility policy during incontinent care was an infection control issue; cross-contamination to that resident, or the spread of infection to others. (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: 675560 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 675560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Village Nursing and Rehabilitation Center 169 Lake Park Rd Lewisville, TX 75057 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)