Health inspection·October 12, 2023

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 of transmission of communicable diseases and infections for 1 ( Resident # 26) of 2 residents reviewed for infection control. Residents Affected - Few LVN B failed to perform hand hygiene while performing wound and incontient care for Resident #26. This failure could place residents at risk for cross contamination and infection. Findings include: Record review of Resident #26's face sheet, dated 10/11/2023, reflected a [AGE] year-old female who was admitted to the facility on 08/312022. Resident #26 had diagnoses which included Atrial Fibrillation (irregular heart rate), Hypertension (elevated blood pressure), Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), Pressure ulcer of sacral region (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and Non Pressure Chronic Ulcer ( a wound caused by poor circulation to the lower extremities). Record review of Resident #26's significant change MDS , dated 7/25/2023, reflected a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #26 physician orders, dated 9/27/2023, reflected clean wound to right anterior ankle with wound cleanser, apply alginate pad and cover with dressing. Clean wound to left lateral foot with wound cleanser, apply alginate pad and cover with dressing. Clean wound to coccyx with wound cleanser, pack with alginate pad, cover with dressing. Clean blister to right lateral foot, cleanse with wound cleanser and cover with dressing. Observation on 10/11/2023 at 1:30 PM revealed LVN B preformed wound care on Resident #26. LVN cleaned and placed ordered wound care and dressing on right anterior ankle without changing gloves or preforming hand hygiene. LVN B then cleaned and placed ordered wound care on the left lateral foot without changing gloves or preforming hand hygiene. LVN B then removed gloves, preformed hand hygiene, and left the room to gather supplies. LVN B performed hand hygiene upon return to room. LVN B preformed incontinent care and changed gloves without preforming hand hygiene. LVN B removed soiled dressing to coccyx, cleaned the wound, applied ordered treatment and applied dressing without changing gloves or preforming hand hygiene. LVN B then changed gloves and preformed wound care to the right foot, removing the dressing, cleaning the wound and applying a clean dressing without changing gloves or preforming hand hygiene. (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: 675884 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 675884 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Teague Nursing and Rehabilitation 884 Hwy 84 W Teague, TX 75860 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)