Health inspection·March 12, 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 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 infections for 1 of 7 residents (Resident #1) and 1 of 4 staff (CNA A) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA A washed their hands upon entering rooms, donned appropriate PPE, and washed their hands upon exiting the room of Resident #1 when she was on contact precautions on 3/9/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Record review of Resident #1's facility face sheet, dated 3/13/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a subsequent readmission on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (uncontrolled blood sugar) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 2/10/25, indicated she had a BIMS score of 15, which indicated she was cognitively intact. She had a stage 3 and a stage 4 pressure ulcer. She received antibiotics. Record review of Resident #1's comprehensive care plan, initiated on 2/17/25, indicated she required contact precautions for wound and had the following interventions: .put on gown and gloves prior to entering the resident's room .wash hands or use hand sanitizer prior to entering the room Record review of Resident #1's physician's order summary report, dated 3/10/25, indicated she had the following physician's order, dated 2/7/25: .Contact Precautions every shift for Wound Healing During an observation on 3/10/25 at 11:04 AM, Resident #1's room was observed with a sign at the entrance which read: Contact Precautions and a PPE box was observed outside the doorway with PPE located inside. During an observation on 3/10/25 at 11:12 AM revealed CNA A entered Resident #1's room without donning PPE, and without washing her hands or using sanitizer. The door was left open, and CNA A was observed touching the bedsheets of Resident #1 to straighten them without gloves. She was then observed (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: 675816 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 675816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Pale 2404 Hwy 155 Palestine, TX 75803 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)