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 maintain an infection prevention and control
program designed to provide a safe, sanitary, and comfortable environment to help prevent the
development and transmission of communicable diseases and infections for one (Resident #1) of three
residents reviewed for infection control practices.
Residents Affected - Few
CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to
Resident #1 on 03/29/24.
This failure could place residents at risk for the spread of infection.
Findings included:
Review of Resident #1's face sheet dated 04/01/24, revealed an 84- year- old female admitted to the facility
on 06/06//22 with diagnoses including Covid-19, overactive bladder, gastronomy (feeding tube) and
dementia.
Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required total assistance
with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was
always incontinent of bowel and bladder.
Review of Resident #1's Care Plan dated 02/15/22 revealed he had bowel and bladder incontinence related
to over-active bladder.
Observation of incontinence care for Resident #1 on 03/29/24 at 9:50 a.m. revealed CNA A used antiseptic
and donned gloves (after retrieving the gloves her pocket) before commencing care. CNA A removed
Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. CNA A did not
change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine. CNA A
used the same soiled gloves to apply skin protector to Resident #1. She did not wash her hands, change
gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the
resident and fastening. CNA A washed hands before leaving Resident #1's room.
In an interview on 03/29/24 at 10:03 a.m. with CNA A, she revealed she should have changed her gloves
during care. CNA A also stated she should have changed her gloves before retrieving a clean brief and
placing it underneath Resident #1. CNA A was asked why she did not change her gloves. She said she was
nervous. CNA A stated she had infection control training (computer-based learning) about 2 weeks ago.
She has been employed in the facility for 2 month and did not receive training with return demonstration
from the facility. She said the resident could acquire an infection when she did not
(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:
675982
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
675982
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Plaza Nursing and Rehabilitation Center
2210 Howard St
San Angelo, TX 76901
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
follow good infection control practices including not changing gloves before retrieving the resident's clean
brief.
During an interview with the RCN B on 04/01/24 at 4:58p.m., revealed she was aware of some of the
concerns raised about infection control. She stated she expected the aides to follow the facility protocols
during care, one of which was to ensure hand washing or sanitizing hand and change of gloves before
retrieving clean brief. RCN B noted the facility conducts yearly competency training and periodic in-services
if needed.
Review of the facility's Perineal care policy created 04/25/22 reflected:
Purpose:
This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by
providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the
resident skin condition.
Important Points:
o If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from
front to back, prior to performing perineal care.
o Do not wipe more than once with the same surface
o Doffing and discarding of gloves are required if visibly soiled
o Always perform hand hygiene before and after glove use
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675982
If continuation sheet
Page 2 of 2
